Provider Demographics
NPI:1932104288
Name:CLOUSE, KELLY T (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:T
Last Name:CLOUSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2021 PROFESSIONAL CENTER DR STE 101
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4461
Mailing Address - Country:US
Mailing Address - Phone:904-213-9210
Mailing Address - Fax:904-213-9211
Practice Address - Street 1:2021 PROFESSIONAL CENTER DR STE 101
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4461
Practice Address - Country:US
Practice Address - Phone:904-213-9210
Practice Address - Fax:904-213-9211
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1109382084P0800X
WI469742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34564000Medicaid
WI34564000Medicaid
WI082634217Medicare ID - Type Unspecified