Provider Demographics
NPI:1215010194
Name:CLAYTON, KEN R (DO)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:R
Last Name:CLAYTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78-6831 ALII DR STE 411
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-5403
Mailing Address - Country:US
Mailing Address - Phone:808-747-8321
Mailing Address - Fax:
Practice Address - Street 1:78-6831 ALII DR STE 411
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-5403
Practice Address - Country:US
Practice Address - Phone:808-747-8321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 7621207V00000X
AZ3839207V00000X
HI1991207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ911174OtherAHCCCS
AZH82439Medicare UPIN