Basic Information
| Provider Information | |||||||||
| NPI: | 1134593361 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROBERT C. CLINGAN, MD, DERMATOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2080 S FRONTAGE RD | ||||||||
| Address2: | SUITE 113 | ||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391805328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016361658 | ||||||||
| FaxNumber: | 6016361076 | ||||||||
| Practice Location | |||||||||
| Address1: | 2080 S FRONTAGE RD | ||||||||
| Address2: | SUITE 113 | ||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391805328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016361658 | ||||||||
| FaxNumber: | 6016361076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2015 | ||||||||
| LastUpdateDate: | 11/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | CLINGAN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6016361658 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 13005 | MS | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 02258379 | 05 | MS | MEDICAID |