Provider Demographics
NPI:1578575734
Name:CLINTON, JEREMIAH MALACHI (MD)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:MALACHI
Last Name:CLINTON
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:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:212 E CENTRAL AVE STE 440
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-6290
Practice Address - Country:US
Practice Address - Phone:509-252-1977
Practice Address - Fax:509-465-3026
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML20007417207X00000X
WAMD00047792207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1578575734Medicaid
WA1578575734Medicaid
ID1578575734Medicaid
WA1578575734Medicaid