Provider Demographics
NPI:1184706756
Name:CLANTON, WAVERLY B (MD)
Entity type:Individual
Prefix:
First Name:WAVERLY
Middle Name:B
Last Name:CLANTON
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 1:1357 W 103RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-2392
Mailing Address - Country:US
Mailing Address - Phone:773-238-0800
Mailing Address - Fax:773-238-0800
Practice Address - Street 1:1357 W 103RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-2392
Practice Address - Country:US
Practice Address - Phone:773-238-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068032207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C46244Medicare UPIN