Provider Demographics
NPI:1760569339
Name:BAUCOM, CLAIRALYN LOIS (MD)
Entity Type:Individual
Prefix:
First Name:CLAIRALYN
Middle Name:LOIS
Last Name:BAUCOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CLAIRALYN
Other - Middle Name:CATHERINE
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18MDOS
Mailing Address - Street 2:PSC 80 BOX 15477
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367-5142
Mailing Address - Country:US
Mailing Address - Phone:315-630-4542
Mailing Address - Fax:
Practice Address - Street 1:KADENA PEDIATRIC CLINIC
Practice Address - Street 2:18MDG / SGHQ UNIT 5142
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96367-5142
Practice Address - Country:US
Practice Address - Phone:315-630-4542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240222208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice