Provider Demographics
NPI:1326100835
Name:CLEWELL, KATHY MARIE (MD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:MARIE
Last Name:CLEWELL
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 1:15525 POMERADO RD.
Mailing Address - Street 2:SUITE A-4
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064
Mailing Address - Country:US
Mailing Address - Phone:858-592-7040
Mailing Address - Fax:858-592-7049
Practice Address - Street 1:15525 POMERADO RD A-4
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064
Practice Address - Country:US
Practice Address - Phone:858-592-7040
Practice Address - Fax:858-592-7049
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81095207R00000X
CAG018095207R00000X
CAG08109C207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine