Provider Demographics
NPI:1134593361
Name:ROBERT C. CLINGAN, MD, DERMATOLOGY
Entity type:Organization
Organization Name:ROBERT C. CLINGAN, MD, DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:CLINGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-636-1658
Mailing Address - Street 1:2080 S FRONTAGE RD
Mailing Address - Street 2:SUITE 113
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5328
Mailing Address - Country:US
Mailing Address - Phone:601-636-1658
Mailing Address - Fax:601-636-1076
Practice Address - Street 1:2080 S FRONTAGE RD
Practice Address - Street 2:SUITE 113
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5328
Practice Address - Country:US
Practice Address - Phone:601-636-1658
Practice Address - Fax:601-636-1076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-27
Last Update Date:2015-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13005261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02258379Medicaid
MS02258379Medicaid