Provider Demographics
NPI:1144264045
Name:DAINES, CLARK R (MD)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:R
Last Name:DAINES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1820 E 17TH ST
Mailing Address - Street 2:STE 230
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6469
Mailing Address - Country:US
Mailing Address - Phone:208-529-9779
Mailing Address - Fax:208-542-2756
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7533
Practice Address - Country:US
Practice Address - Phone:208-529-6050
Practice Address - Fax:208-529-7085
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM11914207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM11914OtherSTATE LICENSE
ID79892OtherBLUE CROSS IDAHO
ID20002833Medicare UPIN