Provider Demographics
NPI:1255593802
Name:CLIFFORD, KATHERINE (DO)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:CLIFFORD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33087 VENDANGE DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-4538
Mailing Address - Country:US
Mailing Address - Phone:818-730-4123
Mailing Address - Fax:
Practice Address - Street 1:44274 GEORGE CUSHMAN CT
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-5945
Practice Address - Country:US
Practice Address - Phone:951-587-0992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13682208000000X
NVDO 1625208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVDO 1625OtherMEDICAL LICENSE
NV1255593802Medicaid
NVFK867ZMedicare PIN