Provider Demographics
NPI:1558965889
Name:KITZMILLER, CLINTON ROGER
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:ROGER
Last Name:KITZMILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-8824
Mailing Address - Country:US
Mailing Address - Phone:301-379-1580
Mailing Address - Fax:
Practice Address - Street 1:1000 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-8824
Practice Address - Country:US
Practice Address - Phone:304-292-2108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty