Provider Demographics
NPI:1891898326
Name:CLINGMAN, STEPHEN R (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:CLINGMAN
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1027
Practice Address - Country:US
Practice Address - Phone:260-569-2120
Practice Address - Fax:260-569-2121
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-101503207Q00000X
IN01070531A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101503Medicaid
IL579180Medicare ID - Type Unspecified
IL036101503Medicaid