Provider Demographics
NPI:1063401297
Name:MOEN, CLINTON T (MD)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:T
Last Name:MOEN
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 1:2711 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55812-1538
Mailing Address - Country:US
Mailing Address - Phone:218-724-0649
Mailing Address - Fax:
Practice Address - Street 1:2711 E 5TH ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812
Practice Address - Country:US
Practice Address - Phone:218-724-0649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25367174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30451200Medicaid
WIB55178Medicare UPIN
WI30451200Medicaid