Provider Demographics
NPI:1366416885
Name:PHELPS, CLARISSA M (MD)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:M
Last Name:PHELPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:D
Other - Last Name:MOXLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1180 NEWFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-1409
Mailing Address - Country:US
Mailing Address - Phone:314-888-5233
Mailing Address - Fax:
Practice Address - Street 1:1180 NEWFIELD AVE
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-1409
Practice Address - Country:US
Practice Address - Phone:314-888-5233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P002770084OtherRAILROAD MEDICARE
KY000000546325OtherANTHEM BLUE CROSS
027299800OtherBLACK LUNG
KY000000546325OtherANTHEM BLUE CROSS
KYK046130Medicare PIN
I35410Medicare UPIN