Provider Demographics
NPI:1316965635
Name:CLAYBAUGH, HARRY CARL III (MD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:CARL
Last Name:CLAYBAUGH
Suffix:III
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:PO BOX 240086
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-9186
Mailing Address - Country:US
Mailing Address - Phone:310-445-2951
Mailing Address - Fax:310-479-1459
Practice Address - Street 1:1516 COTNER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3303
Practice Address - Country:US
Practice Address - Phone:310-445-2951
Practice Address - Fax:310-479-1459
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA243372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A243370OtherBLUE SHIELD
CA00A243370Medicaid
CAA23926Medicare UPIN
CAAP758WMedicare PIN
CAAP758XMedicare PIN
CAAP758YMedicare PIN
CA00A243370Medicaid