Provider Demographics
NPI:1639330350
Name:UPSHAW, CLIFFORD WAYNE
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:WAYNE
Last Name:UPSHAW
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 1:3250 W GRANT LINE RD
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95304-8427
Mailing Address - Country:US
Mailing Address - Phone:209-836-3937
Mailing Address - Fax:209-836-3466
Practice Address - Street 1:3250 W GRANT LINE RD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95304-8427
Practice Address - Country:US
Practice Address - Phone:209-836-3937
Practice Address - Fax:209-836-3466
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12241T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist