Provider Demographics
NPI:1508842055
Name:LUSK, CLIFFORD DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:DALE
Last Name:LUSK
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:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-777-7042
Mailing Address - Fax:843-777-7102
Practice Address - Street 1:101 WILLIAM H. JOHNSON STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2776
Practice Address - Country:US
Practice Address - Phone:843-777-7500
Practice Address - Fax:843-777-7533
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16366207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC163665Medicaid
SCF54442Medicare UPIN
SC163665Medicaid