Provider Demographics
NPI:1528053188
Name:CLAYTON, KEVIN J (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:CLAYTON
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 1:2891 MOMENTUM PLACE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5328
Mailing Address - Country:US
Mailing Address - Phone:231-935-5800
Mailing Address - Fax:231-935-5799
Practice Address - Street 1:1200 SIXTH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2369
Practice Address - Country:US
Practice Address - Phone:231-935-5800
Practice Address - Fax:231-935-5799
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010007207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2995924Medicaid
MI3686014Medicare PIN
MI0B84507005Medicare ID - Type Unspecified
MI2995924Medicaid