Provider Demographics
NPI:1457662512
Name:CLOUGH, DAVID L
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:L
Last Name:CLOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16783 IVES STREET EXT
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5312
Mailing Address - Country:US
Mailing Address - Phone:315-788-5377
Mailing Address - Fax:
Practice Address - Street 1:16783 IVES STREET EXT
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5312
Practice Address - Country:US
Practice Address - Phone:315-788-5377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032662-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics