Provider Demographics
NPI:1356336440
Name:JUDY, CLAINE DOYLE (DO)
Entity type:Individual
Prefix:DR
First Name:CLAINE
Middle Name:DOYLE
Last Name:JUDY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:755 HOSPITAL WAY
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2795
Mailing Address - Country:US
Mailing Address - Phone:208-233-8444
Mailing Address - Fax:208-233-6920
Practice Address - Street 1:755 HOSPITAL WAY
Practice Address - Street 2:STE A-5
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2717
Practice Address - Country:US
Practice Address - Phone:208-233-8444
Practice Address - Fax:208-233-6920
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-279208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDS3895OtherBLUE CROSS OF IDAHO
ID000010138779OtherREGENCE BLUE SHIELD OF ID
CAXPY200851Medicaid
ID000010138779OtherREGENCE BLUE SHIELD OF ID
IDG85624Medicare UPIN