Basic Information
Provider Information | |||||||||
NPI: | 1063622058 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEITH | ||||||||
FirstName: | CLIFFORD | ||||||||
MiddleName: | VOYD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | II | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6727 NW MONTICELLO TER | ||||||||
Address2: |   | ||||||||
City: | PARKVILLE | ||||||||
State: | MO | ||||||||
PostalCode: | 641525706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8166797275 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2800 CLAY EDWARDS DR | ||||||||
Address2: |   | ||||||||
City: | NORTH KANSAS CITY | ||||||||
State: | MO | ||||||||
PostalCode: | 641163220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8163467220 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2007 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   | IL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 2008011546 | MO | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | P00635001 | 01 | MO | RR MEDICARE GROUP CD1534 | OTHER | 1063622058 | 05 | MO |   | MEDICAID | 40260015 | 01 | MO | BCBS OF KC MO GROUP 10408016 | OTHER |