Provider Demographics
NPI:1457840068
Name:MONTECALVO, CLARICE (MD)
Entity type:Individual
Prefix:
First Name:CLARICE
Middle Name:
Last Name:MONTECALVO
Suffix:
Gender:F
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:P.O. BOX 4168
Mailing Address - Street 2:
Mailing Address - City:POCATELLA
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4168
Mailing Address - Country:US
Mailing Address - Phone:208-239-1035
Mailing Address - Fax:208-239-3626
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-239-2481
Practice Address - Fax:208-239-3691
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYC3972207Q00000X
ID7371563207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine