Provider Demographics
NPI:1093800401
Name:CLARAVALL, ODILON (MD)
Entity Type:Individual
Prefix:
First Name:ODILON
Middle Name:
Last Name:CLARAVALL
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 1:42 TIDEWATER DRIVE
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973
Mailing Address - Country:US
Mailing Address - Phone:302-337-0949
Mailing Address - Fax:
Practice Address - Street 1:1124 SOUTH CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:DE
Practice Address - Zip Code:19956
Practice Address - Country:US
Practice Address - Phone:302-875-7753
Practice Address - Fax:302-875-7966
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0005393207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G83199Medicare UPIN