Provider Demographics
NPI:1952563801
Name:PROTACK, CLINTON DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:DAVID
Last Name:PROTACK
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 1:520 UPPER CHESAPEAKE DR STE 306
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4375
Mailing Address - Country:US
Mailing Address - Phone:410-879-2006
Mailing Address - Fax:410-879-0428
Practice Address - Street 1:520 UPPER CHESAPEAKE DR STE 306
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4375
Practice Address - Country:US
Practice Address - Phone:410-879-2006
Practice Address - Fax:410-879-0428
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD872732086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery