Provider Demographics
NPI:1265426050
Name:CLAMP, CHRYSTAL G (MD)
Entity type:Individual
Prefix:MRS
First Name:CHRYSTAL
Middle Name:G
Last Name:CLAMP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 DREW ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-315-7496
Mailing Address - Fax:
Practice Address - Street 1:4211 VAN DYKE RD STE 101
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-8005
Practice Address - Country:US
Practice Address - Phone:813-960-4026
Practice Address - Fax:813-443-8166
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2024-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL168018207R00000X
TN39577207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00269713OtherRR MEDICARE
TN3331800Medicaid
KY64101876Medicaid
TNP00269713OtherRR MEDICARE
TN3331800Medicaid