Provider Demographics
NPI:1992707285
Name:MERRILL, CLINTON FRANKLIN JR (MD)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:FRANKLIN
Last Name:MERRILL
Suffix:JR
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 1:15 SHRINE CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-8501
Mailing Address - Country:US
Mailing Address - Phone:307-332-0324
Mailing Address - Fax:307-332-0382
Practice Address - Street 1:15 SHRINE CLUB RD
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-8501
Practice Address - Country:US
Practice Address - Phone:307-332-0324
Practice Address - Fax:307-332-0382
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3277A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY3277AOtherWYOMING MEDICAL LICENSE
NE10025668100Medicaid
WY141495000Medicaid
CO63235552Medicaid
WY311538OtherBCBS
WYW27189OtherMEDICARE PTAN (WY)
NE10025668100Medicaid