Provider Demographics
NPI:1699769315
Name:CLINTON, RICHARD B (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
Last Name:CLINTON
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 1:1121 SITUS CT STE 170
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-4279
Mailing Address - Country:US
Mailing Address - Phone:919-834-2767
Mailing Address - Fax:919-834-0234
Practice Address - Street 1:3200 BLUE RIDGE RD STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-8087
Practice Address - Country:US
Practice Address - Phone:919-781-1437
Practice Address - Fax:919-787-4870
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-000302085R0202X
SC315212085R0202X, 2085R0204X
GA0521582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP01286586OtherRAIL ROAD MEDICARE
SC315215Medicaid
SCAA44345277Medicare PIN
SCAA44346868Medicare PIN
SCH91384Medicare UPIN
SC315215Medicaid
SCAA44347126Medicare PIN
SCAA44345281Medicare PIN
SCAA44347555Medicare PIN
SCAA44345282Medicare PIN
SCAA44346834Medicare PIN
SCAA44345282Medicare PIN