Provider Demographics
NPI:1568429694
Name:WEDDINGTON, CLARISSA HAWTHORNE (MD)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:HAWTHORNE
Last Name:WEDDINGTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:
Other - Last Name:POWLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:960 LEARNING WAY
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32306-4178
Mailing Address - Country:US
Mailing Address - Phone:850-644-6230
Mailing Address - Fax:850-644-4251
Practice Address - Street 1:960 LEARNING WAY
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32306-4178
Practice Address - Country:US
Practice Address - Phone:850-644-6230
Practice Address - Fax:850-644-4251
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 57985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11434ZMedicare ID - Type Unspecified
E59549Medicare UPIN