Provider Demographics
NPI:1437131901
Name:TWADDELL, CLINTON WARREN JR (MD)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:WARREN
Last Name:TWADDELL
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 1:220 N RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-4115
Mailing Address - Country:US
Mailing Address - Phone:817-556-4800
Mailing Address - Fax:817-774-5015
Practice Address - Street 1:220 N RIDGEWAY DR
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4115
Practice Address - Country:US
Practice Address - Phone:817-556-4800
Practice Address - Fax:817-774-5015
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6668208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX098679603Medicaid
TXF18818Medicare UPIN
TX00K14PMedicare PIN