Provider Demographics
NPI:1699038125
Name:KETCHEL, CLINT (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINT
Middle Name:
Last Name:KETCHEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 VALE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5218
Mailing Address - Country:US
Mailing Address - Phone:760-631-5000
Mailing Address - Fax:760-414-3892
Practice Address - Street 1:30195 FRASER DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-7006
Practice Address - Country:US
Practice Address - Phone:951-252-2720
Practice Address - Fax:760-414-3892
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100963207Q00000X
CAA135564207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine