Provider Demographics
NPI:1578529327
Name:SMITH, CLIFTON DELOS JR (MD)
Entity Type:Individual
Prefix:
First Name:CLIFTON
Middle Name:DELOS
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:NORTH VASSALBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04962-0247
Mailing Address - Country:US
Mailing Address - Phone:207-873-6173
Mailing Address - Fax:207-873-4514
Practice Address - Street 1:905 MAIN ST
Practice Address - Street 2:
Practice Address - City:VASSALBORO
Practice Address - State:ME
Practice Address - Zip Code:04989-3107
Practice Address - Country:US
Practice Address - Phone:207-873-6173
Practice Address - Fax:207-873-4514
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME011712207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME000927OtherANTHEM
1041270OtherAETNA HMO
110084669OtherRAILROAD MEDICARE
5201627OtherAETNA NON-HMO
D78788OtherHARVARD PILGRIM
D78788OtherHARVARD PILGRIM
5201627OtherAETNA NON-HMO