1104142686 NPI number — DR. CRAIG CLIFFORD DPM

Table of content: DR. CRAIG CLIFFORD DPM (NPI 1104142686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104142686 NPI number — DR. CRAIG CLIFFORD DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLIFFORD
Provider First Name:
CRAIG
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104142686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4300 TALBOT RD S STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98055-6238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-277-3668
Provider Business Mailing Address Fax Number:
425-277-0732

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34612 6TH AVE S
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-8723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-838-8552
Provider Business Practice Location Address Fax Number:
253-874-6089
Provider Enumeration Date:
04/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  PO60290950 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G8912601 . This is a "MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 455507 . This is a "LNI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2020061 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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