Provider Demographics
NPI:1508942715
Name:CLISHAM, PAUL RONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:RONALD
Last Name:CLISHAM
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 1:1430 TULANE AVE
Mailing Address - Street 2:SL-11
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2632
Mailing Address - Country:US
Mailing Address - Phone:504-988-5217
Mailing Address - Fax:504-988-1846
Practice Address - Street 1:1415 TULANE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2600
Practice Address - Country:US
Practice Address - Phone:504-988-5271
Practice Address - Fax:504-988-7655
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016589207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1920126Medicaid
LA5N643Medicare PIN
LAC04109Medicare UPIN