Provider Demographics
NPI:1306144613
Name:MIELKE, CLARENCE HAROLD (MD)
Entity type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:HAROLD
Last Name:MIELKE
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 1:25415 E MISSION AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-9586
Mailing Address - Country:US
Mailing Address - Phone:509-926-2600
Mailing Address - Fax:509-891-2737
Practice Address - Street 1:25415 E MISSION AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-9586
Practice Address - Country:US
Practice Address - Phone:509-926-2600
Practice Address - Fax:509-891-2737
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWAMD00025451174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist