Provider Demographics
NPI:1316296346
Name:MAYES, CLINTON (NAVY IDC)
Entity type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:
Last Name:MAYES
Suffix:
Gender:M
Credentials:NAVY IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 BURNINGTREE DR
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3100
Mailing Address - Country:US
Mailing Address - Phone:804-590-7763
Mailing Address - Fax:
Practice Address - Street 1:USS PITTSBURGH
Practice Address - Street 2:SSN720
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09582-2400
Practice Address - Country:US
Practice Address - Phone:804-590-7763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman