Provider Demographics
NPI:1497291983
Name:CLINTON, JOHN ANDREW
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:CLINTON
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:PO BOX 775985
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5985
Mailing Address - Country:US
Mailing Address - Phone:317-770-6900
Mailing Address - Fax:317-770-6911
Practice Address - Street 1:14535A HAZEL DELL PKWY
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46033-9401
Practice Address - Country:US
Practice Address - Phone:317-770-3777
Practice Address - Fax:317-705-4391
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006969A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300000658Medicaid