Provider Demographics
NPI:1801801493
Name:RADCLIFF, LAUTREC WILSON (MD)
Entity type:Individual
Prefix:
First Name:LAUTREC
Middle Name:WILSON
Last Name:RADCLIFF
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 1:2609 VILLAGE PROFESSIONAL DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-5442
Mailing Address - Country:US
Mailing Address - Phone:334-749-6523
Mailing Address - Fax:334-742-0242
Practice Address - Street 1:2609 VILLAGE PROFESSIONAL DR
Practice Address - Street 2:SUITE 3
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5442
Practice Address - Country:US
Practice Address - Phone:334-749-6523
Practice Address - Fax:334-742-0242
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14179207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51038111OtherBCBS LAFAYETTE
AL51079130OtherBCBS LANGDALE
AL1801801493OtherNPI
AL528701590Medicaid
ALCC1726OtherRRMC
AL51079131OtherBCBS OPELIKA
AL51520919OtherBCBS AUBURN
AL51079111OtherBCBS DADEVILLE
AL51079203OtherBCBS TUSKEGEE
C73937Medicare UPIN
000038111Medicare ID - Type UnspecifiedLAFAYETTE
AL51079111OtherBCBS DADEVILLE
AL51038111OtherBCBS LAFAYETTE
00079131Medicare ID - Type UnspecifiedOPELIKA
AL528701590Medicaid