Provider Demographics
NPI:1962821611
Name:MAYO, CLARENCE
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:
Last Name:MAYO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 BLACKHEATH
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-7482
Mailing Address - Country:US
Mailing Address - Phone:757-209-1060
Mailing Address - Fax:757-345-0125
Practice Address - Street 1:153 BLACKHEATH
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-7482
Practice Address - Country:US
Practice Address - Phone:757-209-1060
Practice Address - Fax:757-345-0125
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1586305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service