Basic Information
Provider Information | |||||||||
NPI: | 1104142686 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLIFFORD | ||||||||
FirstName: | CRAIG | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 34612 6TH AVE S | ||||||||
Address2: | SUITE 300 | ||||||||
City: | FEDERAL WAY | ||||||||
State: | WA | ||||||||
PostalCode: | 980038723 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538388552 | ||||||||
FaxNumber: | 2538746089 | ||||||||
Practice Location | |||||||||
Address1: | 34612 6TH AVE S | ||||||||
Address2: | SUITE 300 | ||||||||
City: | FEDERAL WAY | ||||||||
State: | WA | ||||||||
PostalCode: | 980038723 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538388552 | ||||||||
FaxNumber: | 2538746089 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2010 | ||||||||
LastUpdateDate: | 12/07/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | PO60290950 | WA | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 0297935 | 01 | WA | L&I | OTHER | 0298552 | 01 | WA | L&I | OTHER | G8912602 | 01 | WA | MEDICARE | OTHER | G8912601 | 01 | WA | MEDICARE | OTHER |