Provider Demographics
NPI:1205887338
Name:CLATTERBUCK, RICHARD ELWOOD (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ELWOOD
Last Name:CLATTERBUCK
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-5459
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-579-5459
Practice Address - Fax:601-268-5733
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19675207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS7210176OtherATENA
AL009913220Medicaid
MS06778577Medicaid
MD180401400Medicaid
MS06778577Medicaid
MS06778577Medicaid
MD180401400Medicaid
MD180401400Medicaid