Provider Demographics
NPI:1689638975
Name:WLODAVER, CLIFFORD GROVER (MD)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:GROVER
Last Name:WLODAVER
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 1:8121 NATIONAL AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-7530
Mailing Address - Country:US
Mailing Address - Phone:405-737-3100
Mailing Address - Fax:405-737-3109
Practice Address - Street 1:8121 NATIONAL AVE
Practice Address - Street 2:STE 310
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-7530
Practice Address - Country:US
Practice Address - Phone:405-737-3100
Practice Address - Fax:405-737-3109
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13905207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100006140CMedicaid
OKOKB5274Medicare PIN
E16483Medicare UPIN