Provider Demographics
NPI:1407822406
Name:CLUTTS, DAVID D (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:D
Last Name:CLUTTS
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:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-549-5361
Mailing Address - Fax:618-549-5128
Practice Address - Street 1:2601 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1031
Practice Address - Country:US
Practice Address - Phone:618-549-5361
Practice Address - Fax:618-549-5128
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-078587208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL027516OtherHEALTH ALLIANCE
IL036078587Medicaid
IL3932056OtherBCBS OF IL
IL7210895OtherAETNA
IL20016640OtherRR MEDICARE
IL142410OtherHEALTHLINK INSURANCE
IL324130OtherGHP
IL42496OtherGHP
IL027516OtherHEALTH ALLIANCE
IL142410OtherHEALTHLINK INSURANCE
IL614350Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILK45816Medicare PIN
IL214881Medicare PIN