Provider Demographics
NPI:1134237308
Name:COSTLEY, CLIFFORD M (MD)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:M
Last Name:COSTLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3800 S NATIONAL AVE
Mailing Address - Street 2:#540
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5209
Mailing Address - Country:US
Mailing Address - Phone:417-236-2600
Mailing Address - Fax:417-236-2619
Practice Address - Street 1:2200 E CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-6149
Practice Address - Country:US
Practice Address - Phone:417-236-2600
Practice Address - Fax:417-236-2619
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO36273207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201967833Medicaid
MO201967833Medicaid
MOCC9890Medicare PIN
MO080071102Medicare PIN