Provider Demographics
NPI:1780959932
Name:CLAYTON, KATHERINE IDA (DO)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:IDA
Last Name:CLAYTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:IDA
Other - Last Name:GUTHRIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1000 36TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4862
Practice Address - Country:US
Practice Address - Phone:772-567-4311
Practice Address - Fax:772-563-4641
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2020-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS13192208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist