Provider Demographics
NPI:1235311127
Name:CLIFFORD, MARK EDWIN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWIN
Last Name:CLIFFORD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2491 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:FORT MITCHELL
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3056
Mailing Address - Country:US
Mailing Address - Phone:859-331-5400
Mailing Address - Fax:859-331-5400
Practice Address - Street 1:2491 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FORT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41017-3056
Practice Address - Country:US
Practice Address - Phone:859-331-5400
Practice Address - Fax:859-331-5400
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-03
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4429111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85044295Medicaid
P300037052Medicare PIN