Provider Demographics
NPI:1730285123
Name:CLOS, AUTUMN PATRICIA (MD)
Entity Type:Individual
Prefix:DR
First Name:AUTUMN
Middle Name:PATRICIA
Last Name:CLOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33353 YUCAIPA BLVD
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-2018
Mailing Address - Country:US
Mailing Address - Phone:909-790-7900
Mailing Address - Fax:
Practice Address - Street 1:33353 YUCAIPA BLVD
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399
Practice Address - Country:US
Practice Address - Phone:909-790-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54711208000000X
IN01078576A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1730285123OtherNPI
IN300002637Medicaid
CA1730285123OtherCALIFORNIA CHILDREN'S SERVICES (CCS)
F48413Medicare UPIN
N27100007Medicare PIN