Provider Demographics
NPI:1124119417
Name:CLAYBORN, ROBERT LEE SR (CO)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEE
Last Name:CLAYBORN
Suffix:SR
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:214 ROCK CREEK CT
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-5542
Mailing Address - Country:US
Mailing Address - Phone:662-292-3887
Mailing Address - Fax:
Practice Address - Street 1:100 EMANCIPATION DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667
Practice Address - Country:US
Practice Address - Phone:757-722-9961
Practice Address - Fax:757-728-3173
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSCO0036711744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS4522510001Medicare ID - Type Unspecified