Provider Demographics
NPI:1962444620
Name:YATES, CLARENCE BURL (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:BURL
Last Name:YATES
Suffix:
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 1:3725 11TH CR
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4804
Mailing Address - Country:US
Mailing Address - Phone:772-410-0155
Mailing Address - Fax:
Practice Address - Street 1:3725 11TH CR
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4804
Practice Address - Country:US
Practice Address - Phone:772-410-0155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME766552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273820100Medicaid
FLU5436ZMedicare PIN
H23067Medicare UPIN
FL273820100Medicaid