Provider Demographics
NPI:1558320846
Name:BARNETT, CLARENCE RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:RICHARD
Last Name:BARNETT
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 1:650 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ODESSA
Mailing Address - State:MI
Mailing Address - Zip Code:48849-1274
Mailing Address - Country:US
Mailing Address - Phone:616-374-8259
Mailing Address - Fax:
Practice Address - Street 1:1020 4TH AVE
Practice Address - Street 2:
Practice Address - City:LAKE ODESSA
Practice Address - State:MI
Practice Address - Zip Code:48849-1004
Practice Address - Country:US
Practice Address - Phone:616-374-8881
Practice Address - Fax:616-374-4220
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047150207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0130191OtherPHP KALAMAZOO PLAN
MI1560127Medicaid
MI0170558OtherPHP MEDICAID PLAN
MI0340028OtherBCBS
MI0100558OtherPHP LANSING PLAN
MI0130191OtherPHP KALAMAZOO PLAN
MIA76004Medicare UPIN