Provider Demographics
NPI:1508965161
Name:CLONINGER, FRED S (OD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:S
Last Name:CLONINGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:406 S BROAD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4304
Mailing Address - Country:US
Mailing Address - Phone:704-865-3731
Mailing Address - Fax:704-864-5736
Practice Address - Street 1:406 S BROAD ST
Practice Address - Street 2:SUITE A
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4304
Practice Address - Country:US
Practice Address - Phone:704-865-3731
Practice Address - Fax:704-864-5736
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC804152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC410009765OtherRAILROAD MEDICARE
NC8909163Medicaid
NC0554550001Medicare NSC
NC410009765OtherRAILROAD MEDICARE