Provider Demographics
NPI:1720094097
Name:CLINTON, EDMOND JACKSON III (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:JACKSON
Last Name:CLINTON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:65 N MADISON AVE STE 707
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2046
Mailing Address - Country:US
Mailing Address - Phone:626-792-1135
Mailing Address - Fax:626-792-9793
Practice Address - Street 1:65 N MADISON AVE STE 707
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2046
Practice Address - Country:US
Practice Address - Phone:626-792-1135
Practice Address - Fax:626-792-9793
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG029665207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44106Medicare UPIN