Provider Demographics
NPI:1235130444
Name:NETHERLAND, CLINTON AVERY (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:AVERY
Last Name:NETHERLAND
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 1:1400 PERSHING HWY
Mailing Address - Street 2:
Mailing Address - City:SMACKOVER
Mailing Address - State:AR
Mailing Address - Zip Code:71762-2300
Mailing Address - Country:US
Mailing Address - Phone:870-725-3471
Mailing Address - Fax:870-725-3041
Practice Address - Street 1:1400 PERSHING HWY
Practice Address - Street 2:
Practice Address - City:SMACKOVER
Practice Address - State:AR
Practice Address - Zip Code:71762-2300
Practice Address - Country:US
Practice Address - Phone:870-725-3471
Practice Address - Fax:870-725-3471
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2023-03-07
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
ARE1883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA14266ROtherLA STATE MEDICAL LICENSE
ARE1883OtherAR MEDICAL LICENSE
AR530572OtherMEDICARE
AR135730001Medicaid
AR135730001Medicaid