Provider Demographics
NPI:1821234717
Name:PACE, CLINTON J JR (MD)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:J
Last Name:PACE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CLINTON
Other - Middle Name:
Other - Last Name:PACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:100 MERCY WAY
Mailing Address - Street 2:STE 440
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4524
Mailing Address - Country:US
Mailing Address - Phone:417-781-4404
Mailing Address - Fax:417-781-5845
Practice Address - Street 1:100 MERCY WAY STE 440
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4524
Practice Address - Country:US
Practice Address - Phone:417-781-4404
Practice Address - Fax:417-781-5845
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1750208600000X, 2086S0102X, 2086S0127X
MO2015004740208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1821234717Medicaid
TX8CX885OtherBLUE CROSS BLUE SHIELD
TXTXB136978Medicare PIN
MO1821234717Medicaid