Provider Demographics
NPI:1508871153
Name:CLERC, DANIEL T (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:T
Last Name:CLERC
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 1:3021 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2369
Mailing Address - Country:US
Mailing Address - Phone:360-825-6511
Mailing Address - Fax:360-825-6536
Practice Address - Street 1:3021 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2369
Practice Address - Country:US
Practice Address - Phone:360-825-6511
Practice Address - Fax:360-825-6536
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043068207Q00000X, 207QS1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0180969OtherSTATE L&I
WA0290515OtherSTATE L&I
WA8381014Medicaid
WA0180969OtherSTATE L&I
WA8381014Medicaid
WAG8906438Medicare PIN
WAG8906992Medicare PIN
8800820Medicare PIN
8866294Medicare PIN