Provider Demographics
NPI:1154696326
Name:LAURITSEN, CLINTON (DO)
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:LAURITSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 WALNUT ST
Mailing Address - Street 2:SUITE 200, ROOM 232 TJUH HEADACHE CENTER
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:215-955-5266
Mailing Address - Fax:844-575-1344
Practice Address - Street 1:900 WALNUT ST
Practice Address - Street 2:SUITE 200, ROOM 232 TJUH HEADACHE CENTER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-955-5266
Practice Address - Fax:844-575-1344
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0182362084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology