Provider Demographics
NPI:1255493086
Name:CLIFTON, MARY B ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:B ROSE
Last Name:CLIFTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COLUMBUS PL APT S46D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-8215
Mailing Address - Country:US
Mailing Address - Phone:231-342-6132
Mailing Address - Fax:
Practice Address - Street 1:830 NW 82ND AVE
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1212
Practice Address - Country:US
Practice Address - Phone:231-342-6132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065488207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4118573Medicaid
MI4301065488OtherLISCENSE NUMBER
MION 43980OtherPROVIDER NUMBER
MI045488OtherMC NUMBER
MION 43980OtherPROVIDER NUMBER
MIG72307Medicare UPIN