Provider Demographics
NPI:1740393115
Name:CLAYTON, KATHRYN ROSE (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ROSE
Last Name:CLAYTON
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 1:107 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-1115
Mailing Address - Country:US
Mailing Address - Phone:770-997-5714
Mailing Address - Fax:770-997-2844
Practice Address - Street 1:107 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-1115
Practice Address - Country:US
Practice Address - Phone:770-997-5714
Practice Address - Fax:770-997-2844
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00753827AMedicaid
GAGRP583Medicare ID - Type Unspecified
GA00753827AMedicaid