Provider Demographics
NPI:1952760308
Name:CLOVIS DERMATOLOGY, INC
Entity type:Organization
Organization Name:CLOVIS DERMATOLOGY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-298-7220
Mailing Address - Street 1:275 W HERNDON AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0204
Mailing Address - Country:US
Mailing Address - Phone:559-321-4255
Mailing Address - Fax:
Practice Address - Street 1:275 W HERNDON AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0204
Practice Address - Country:US
Practice Address - Phone:559-321-4255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-14
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A661312Medicare PIN
CABZ121ZMedicare PIN
CAH09074Medicare UPIN