Provider Demographics
NPI:1992794879
Name:ALEXANDER, CLAYTON BERT (DO)
Entity type:Individual
Prefix:DR
First Name:CLAYTON
Middle Name:BERT
Last Name:ALEXANDER
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 1:125 EAST SHORE PARKWAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-5677
Mailing Address - Country:US
Mailing Address - Phone:219-325-0155
Mailing Address - Fax:
Practice Address - Street 1:125 EAST SHORE PARKWAY
Practice Address - Street 2:SUITE D
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350
Practice Address - Country:US
Practice Address - Phone:219-325-0155
Practice Address - Fax:219-324-5291
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001107A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN080025306OtherMEDICARE RAILROAD
IN000000084179OtherBLUE CROSS BLUE SHIELD
IN300016527Medicaid
IN15D0355679OtherCLIA
IN15D0355679OtherCLIA
IN484980BMedicare PIN