Provider Demographics
NPI:1154559912
Name:HAWTHORNE, CLINT ROSS (MD)
Entity type:Individual
Prefix:DR
First Name:CLINT
Middle Name:ROSS
Last Name:HAWTHORNE
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 1:1200 PLEASANT ST
Mailing Address - Street 2:#S-128
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 PLEASANT ST
Practice Address - Street 2:#S-128
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1406
Practice Address - Country:US
Practice Address - Phone:515-241-6076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA40018207P00000X
MN54934207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine