Provider Demographics
NPI:1346248036
Name:CLAN, JOSEPH ALVIN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ALVIN
Last Name:CLAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:5211 COMMERCE CROSSINGS DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40229-2183
Practice Address - Country:US
Practice Address - Phone:502-966-3918
Practice Address - Fax:502-969-3665
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2022-10-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY22815208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY157104OtherSIHO-NCMA
KY64228158Medicaid
KY000000845597OtherANTHEM-NCMA
KY50061767OtherPASSPORT-NCMA
KYK093460Medicare PIN
KY50061767OtherPASSPORT-NCMA
KY0267201Medicare ID - Type Unspecified