Provider Demographics
NPI:1063455541
Name:ALLEN, JOHN CLIFFORD (MS, DAAETS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CLIFFORD
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MS, DAAETS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 531166
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN BROOK
Mailing Address - State:AL
Mailing Address - Zip Code:35253-1166
Mailing Address - Country:US
Mailing Address - Phone:205-567-0832
Mailing Address - Fax:
Practice Address - Street 1:5721 5TH CT S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35212-3211
Practice Address - Country:US
Practice Address - Phone:205-567-0832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2016-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5064173000000X
AL1-083260163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2573723OtherUNITED HEALTH CARE
AZ438196OtherAHCCCS
AZZ131721Medicare PIN