Provider Demographics
NPI:1093525024
Name:CLINTON, ANTONIO
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:CLINTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7111 W OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3168
Mailing Address - Country:US
Mailing Address - Phone:313-808-5673
Mailing Address - Fax:
Practice Address - Street 1:7111 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3168
Practice Address - Country:US
Practice Address - Phone:313-808-5673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-11
Last Update Date:2025-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker