Provider Demographics
NPI:1992071609
Name:CLAYTON, MARY SHANNON (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SHANNON
Last Name:CLAYTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SHANNON
Other - Last Name:ROSADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:
Practice Address - Street 1:3920 DUTCHMANS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4702
Practice Address - Country:US
Practice Address - Phone:502-259-6710
Practice Address - Fax:502-259-6704
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076935A207L00000X
KY57339207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100247940Medicaid
IN201374870Medicaid