Provider Demographics
NPI:1003812561
Name:CLAVENNA, CARL F (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:F
Last Name:CLAVENNA
Suffix:
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 1:600 S ADAMS RD
Mailing Address - Street 2:STE 200
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6863
Mailing Address - Country:US
Mailing Address - Phone:248-646-3733
Mailing Address - Fax:248-642-2566
Practice Address - Street 1:600 S ADAMS RD
Practice Address - Street 2:STE 200
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6863
Practice Address - Country:US
Practice Address - Phone:248-646-3733
Practice Address - Fax:248-642-2566
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054362207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180F321870OtherBLUE CROSS GROUP NUMBER
MI101441OtherCARE CHOICES PIN
MIF48420OtherHAP PIN #
MIC4110OtherM-CARE ID #
MIG5031FOtherBLUE CARE NETWORK GROUP #
MIF48420OtherPPOM
MIN79160001Medicare PIN
MIF48420OtherHAP PIN #
MIG5031FOtherBLUE CARE NETWORK GROUP #
MI101441OtherCARE CHOICES PIN
MIF48420Medicare UPIN
MICN6461Medicare ID - Type UnspecifiedMEDICARE RAILROAD GROUP #