Basic Information
| Provider Information | |||||||||
| NPI: | 1023006533 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLIFFORD | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 678898 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752678898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014233306 | ||||||||
| FaxNumber: | 7195912745 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 BISHOP RANDALL DR | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825203939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073356365 | ||||||||
| FaxNumber: | 3073320312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 10/26/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 5956A | WY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 113014500 | 05 | WY | MEDICAID |