Provider Demographics
NPI:1730122763
Name:CLIFFORD, EDWARD J (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:CLIFFORD
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 204803
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-4803
Mailing Address - Country:US
Mailing Address - Phone:972-254-9399
Mailing Address - Fax:817-527-6610
Practice Address - Street 1:1056 TEXAN TRL
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3703
Practice Address - Country:US
Practice Address - Phone:972-254-9399
Practice Address - Fax:817-527-6610
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2307208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G2290Medicare PIN
TX8F8249Medicare PIN
TX8G2290Medicare ID - Type Unspecified