Provider Demographics
NPI:1497828859
Name:LORD, CLIFTON FREDERICK (MD)
Entity Type:Individual
Prefix:DR
First Name:CLIFTON
Middle Name:FREDERICK
Last Name:LORD
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 1:15 STATE ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:VT
Mailing Address - Zip Code:05089-1201
Mailing Address - Country:US
Mailing Address - Phone:802-674-9400
Mailing Address - Fax:802-674-9410
Practice Address - Street 1:15 STATE ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VT
Practice Address - Zip Code:05089-1201
Practice Address - Country:US
Practice Address - Phone:802-674-9400
Practice Address - Fax:802-674-9410
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420007259207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006638Medicaid
VTB74345Medicare UPIN
VT0004475Medicare PIN