Provider Demographics
NPI:1124592514
Name:CLARY, CAMERON TAYLOR
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:TAYLOR
Last Name:CLARY
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 1:407 SILVER LN
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:36744-5245
Mailing Address - Country:US
Mailing Address - Phone:334-507-8264
Mailing Address - Fax:
Practice Address - Street 1:650 CLINIC DRIVE
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608
Practice Address - Country:US
Practice Address - Phone:251-445-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS12354390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program