Provider Demographics
NPI:1225144173
Name:WANEBO, CLIFFORD KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:KEVIN
Last Name:WANEBO
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 1:810 MAZATLAN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-1773
Mailing Address - Country:US
Mailing Address - Phone:970-243-8946
Mailing Address - Fax:
Practice Address - Street 1:810 MAZATLAN DR
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-1773
Practice Address - Country:US
Practice Address - Phone:970-243-8946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14570208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology