Provider Demographics
NPI:1942293220
Name:CLIFFORD, STEPHEN MICHAEL (MC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:CLIFFORD
Suffix:
Gender:M
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 MERCY DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-7320
Mailing Address - Country:US
Mailing Address - Phone:563-589-8796
Mailing Address - Fax:
Practice Address - Street 1:250 MERCY DR
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-7320
Practice Address - Country:US
Practice Address - Phone:563-589-8796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA211772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0016659Medicaid
IA30056OtherBLUE CROSS BLUE SHIELD IA
WI32620700Medicaid
IA30056OtherBLUE CROSS BLUE SHIELD IA
IA0016659Medicaid