Provider Demographics
NPI:1467441048
Name:PRESTON, CLINTON E (MD)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:E
Last Name:PRESTON
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 1:1700 GEARY ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-6842
Mailing Address - Country:US
Mailing Address - Phone:541-812-5500
Mailing Address - Fax:541-812-5505
Practice Address - Street 1:1700 GEARY ST SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-6842
Practice Address - Country:US
Practice Address - Phone:541-812-5500
Practice Address - Fax:541-812-5505
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6238A207P00000X
ORMD172857207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY311187OtherBLUE CROSS BLUE SHIELD
WY114905900Medicaid
MT0057811Medicaid
WY080179382OtherRAILROAD MEDICARE
MT0057811Medicaid
WYH49101Medicare UPIN