Provider Demographics
NPI:1013062686
Name:KAUFFMAN, CLINTON L (MD)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:L
Last Name:KAUFFMAN
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 1:540 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WINAMAC
Mailing Address - State:IN
Mailing Address - Zip Code:46996-1173
Mailing Address - Country:US
Mailing Address - Phone:574-946-2194
Mailing Address - Fax:574-946-2196
Practice Address - Street 1:540 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WINAMAC
Practice Address - State:IN
Practice Address - Zip Code:46996
Practice Address - Country:US
Practice Address - Phone:574-946-2194
Practice Address - Fax:574-946-2196
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057944A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200444820Medicaid
IN01057944AOtherSTATE LICENSE
IN200444820Medicaid
F85069Medicare UPIN
IN200444820Medicaid
000000526230OtherANTHEM
20-5823934OtherCOMMERICAL