Provider Demographics
NPI:1104937820
Name:CLARKSON CLINIC, PLLC
Entity type:Organization
Organization Name:CLARKSON CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:F
Authorized Official - Last Name:DUVALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-242-2311
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:CLARKSON
Mailing Address - State:KY
Mailing Address - Zip Code:42726-0158
Mailing Address - Country:US
Mailing Address - Phone:270-242-2311
Mailing Address - Fax:270-242-7007
Practice Address - Street 1:625 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSON
Practice Address - State:KY
Practice Address - Zip Code:42726-7044
Practice Address - Country:US
Practice Address - Phone:270-242-2311
Practice Address - Fax:270-242-7007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY14881261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2813857000OtherPASSPORT ADVANTAGE
KY7100011620Medicaid
KY7100011620Medicaid