1912932666 NPI number — DR. CLARISSA DAWN GLOVER-DANQUE O.D.

Table of content: DR. CLARISSA DAWN GLOVER-DANQUE O.D. (NPI 1912932666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912932666 NPI number — DR. CLARISSA DAWN GLOVER-DANQUE O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLOVER-DANQUE
Provider First Name:
CLARISSA
Provider Middle Name:
DAWN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GLOVER
Provider Other First Name:
CLARISSA
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912932666
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
275 W. 28TH STREET
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
YUMA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85364-7304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-782-1980
Provider Business Mailing Address Fax Number:
928-345-2950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 W. 28TH STREET
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
YUMA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85364-7304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-782-1980
Provider Business Practice Location Address Fax Number:
928-345-2950
Provider Enumeration Date:
07/11/2006

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: 152W00000X , with the licence number:  1682 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: S-A73-TA-641 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 2535 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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