Provider Demographics
NPI:1982763330
Name:MAYHALL, CLOVUS GLEN (MD)
Entity Type:Individual
Prefix:
First Name:CLOVUS
Middle Name:GLEN
Last Name:MAYHALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CLOVUS
Other - Middle Name:GLEN
Other - Last Name:MAYHALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-1022
Mailing Address - Country:US
Mailing Address - Phone:409-772-2222
Mailing Address - Fax:
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-1022
Practice Address - Country:US
Practice Address - Phone:409-772-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD3330207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101503402Medicaid
TX010062940Medicare PIN
TXB62442Medicare UPIN
TX80T827Medicare ID - Type Unspecified
TX101503402Medicaid
TXCI5830Medicare PIN