Provider Demographics
NPI:1508858572
Name:SOULTS, CLIFFORD B (MD)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:B
Last Name:SOULTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1001 W FAYETTE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2866
Mailing Address - Country:US
Mailing Address - Phone:315-701-2550
Mailing Address - Fax:315-701-2551
Practice Address - Street 1:739 IRVING AVE STE 600
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1663
Practice Address - Country:US
Practice Address - Phone:315-701-2550
Practice Address - Fax:315-701-2551
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY218599207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02107808Medicaid
NYJ400072359Medicare PIN
H30219Medicare UPIN
NYCC981Medicare PIN