Provider Demographics
NPI:1700802634
Name:CLUTTER, DAVID J (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:CLUTTER
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:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:1702 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-364-3300
Practice Address - Fax:701-364-8906
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9323208000000X
MN45703208000000X
ND5340208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND2346OtherNDBS #
ND676556OtherAMERICA'S PPO/ARAZ #
ND9601OtherSIOUX VALLEY #
MN28732CLOtherMNBS #
NDDA9011015522OtherPREFERRED ONE #
ND15305Medicaid
ND27359CLOtherMNBS #
NDHP19524OtherHEALTHPARTNERS #
NDND100001OtherLHS #
ND1201179OtherMEDICA #
ND1201796OtherMEDICA #
MN10424OtherMNBS #
ND142003OtherUCARE #
MN49788CLOtherMNBS #
ND694882100Medicaid
ND92799CLOtherMNBS #
NDHP19524OtherHEALTHPARTNERS #
ND2346Medicare ID - Type UnspecifiedND MEDICARE #
NDND100001OtherLHS #
ND9601OtherSIOUX VALLEY #
MN379000346Medicare ID - Type UnspecifiedMEDICARE #