Provider Demographics
NPI:1740494418
Name:CLEGG, TRAVIS EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:EDWARD
Last Name:CLEGG
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 1:4101 TECHNOLOGY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-8548
Mailing Address - Country:US
Mailing Address - Phone:812-941-4500
Mailing Address - Fax:
Practice Address - Street 1:4101 TECHNOLOGY AVE
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-8548
Practice Address - Country:US
Practice Address - Phone:812-941-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44976207X00000X
IN01067694A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN768066OtherANTHEM
IN201047300Medicaid
KY50045559OtherKY PASSPORT
IN9087848OtherAETNA
KY7100132700Medicaid