Provider Demographics
NPI:1457456584
Name:PRESCOTT, CLINTON EARL JR (MD)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:EARL
Last Name:PRESCOTT
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 1:296 COTTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4942
Mailing Address - Country:US
Mailing Address - Phone:209-239-2901
Mailing Address - Fax:209-239-8662
Practice Address - Street 1:296 COTTAGE AVE
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4942
Practice Address - Country:US
Practice Address - Phone:209-239-2901
Practice Address - Fax:209-239-8662
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25653207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A256532Medicaid
00A256532Medicare ID - Type Unspecified
CA00A256532Medicaid