Provider Demographics
NPI:1942214580
Name:WALTROUS, CLARENCE L JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:L
Last Name:WALTROUS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:867 DUNCAN DR
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1404
Mailing Address - Country:US
Mailing Address - Phone:646-317-0720
Mailing Address - Fax:
Practice Address - Street 1:63 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-2405
Practice Address - Country:US
Practice Address - Phone:646-317-0720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134427207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2488517OtherUS HEALTHCARE, AETNA
NY01535928Medicaid
NYP2119500OtherOXFORD
NYP2119500OtherOXFORD
NY2488517OtherUS HEALTHCARE, AETNA