Provider Demographics
NPI:1366440687
Name:TATUM, CLIFTON (MD)
Entity Type:Individual
Prefix:
First Name:CLIFTON
Middle Name:
Last Name:TATUM
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 1:234 E GRAY ST
Mailing Address - Street 2:SUITE 850
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1900
Mailing Address - Country:US
Mailing Address - Phone:502-585-1735
Mailing Address - Fax:
Practice Address - Street 1:200 E GRAY ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2012
Practice Address - Country:US
Practice Address - Phone:502-629-7601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY268632085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100356810AMedicaid
KY1052796OtherPASSPORT
KY50005985OtherPASSPORT
KY64268634Medicaid
KY000000308613OtherBC BS
KY000000050041OtherBC BS
IN100356810AMedicaid
KY000000050041OtherBC BS
KY50005985OtherPASSPORT
KY64268634Medicaid