Provider Demographics
NPI:1821523127
Name:SCHAEFER, CLINTON JAMES
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:JAMES
Last Name:SCHAEFER
Suffix:
Gender:M
Credentials:
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 1505
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1505
Mailing Address - Country:US
Mailing Address - Phone:760-728-1900
Mailing Address - Fax:
Practice Address - Street 1:12490 BUSINESS CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5833
Practice Address - Country:US
Practice Address - Phone:760-728-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A202102085R0202X
WAOP6155059390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology