Provider Demographics
NPI:1609873421
Name:MEDBERY, CLINTON AMOS III (MD)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:AMOS
Last Name:MEDBERY
Suffix:III
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 1:535 WAMPLER DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-9176
Mailing Address - Country:US
Mailing Address - Phone:405-210-7471
Mailing Address - Fax:
Practice Address - Street 1:535 WAMPLER DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-9176
Practice Address - Country:US
Practice Address - Phone:405-210-7471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2020-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK168402085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100741070AMedicaid
OK100035170AMedicaid
OK100741070AMedicaid