Provider Demographics
NPI:1750475125
Name:CLANON, DAVID L (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:CLANON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:1100 CENTRAL AVE SE FL 4B
Practice Address - Street 2:PMG HOSPITALISTS
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4930
Practice Address - Country:US
Practice Address - Phone:505-724-6124
Practice Address - Fax:505-724-6125
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM96215207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Q5684Medicaid
NM000Q5684Medicaid
G55553Medicare UPIN