Provider Demographics
NPI:1437112265
Name:CLAYTON, CHARLES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:CLAYTON
Suffix:JR
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 1:2827 W CHELTENHAM AVE
Mailing Address - Street 2:
Mailing Address - City:WYNCOTE
Mailing Address - State:PA
Mailing Address - Zip Code:19095-2931
Mailing Address - Country:US
Mailing Address - Phone:215-884-8815
Mailing Address - Fax:215-884-5550
Practice Address - Street 1:2827 W CHELTENHAM AVE
Practice Address - Street 2:
Practice Address - City:WYNCOTE
Practice Address - State:PA
Practice Address - Zip Code:19095-2931
Practice Address - Country:US
Practice Address - Phone:215-884-8815
Practice Address - Fax:215-884-5550
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037419L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA093548OtherBLUE CROSS/BLUE SHIELD
PA0615552Medicaid
PAC29670Medicare UPIN
PA093548OtherBLUE CROSS/BLUE SHIELD