Provider Demographics
NPI:1952497810
Name:CAMPBELL, CLAY I (MD)
Entity Type:Individual
Prefix:
First Name:CLAY
Middle Name:I
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 SO 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254
Mailing Address - Country:US
Mailing Address - Phone:208-847-3847
Mailing Address - Fax:208-847-1620
Practice Address - Street 1:166 SO 5TH ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1557
Practice Address - Country:US
Practice Address - Phone:208-847-3847
Practice Address - Fax:208-847-1620
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT90015207Q00000X
IDM-6065207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY110040800Medicaid
ID806820000Medicaid
ID002743700Medicaid