Basic Information
| Provider Information | |||||||||
| NPI: | 1346205507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SALMON | ||||||||
| FirstName: | CLIFTON | ||||||||
| MiddleName: | WALES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 300 | ||||||||
| Address2: | 104 MORRIS CIRCLE | ||||||||
| City: | HOMER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710400300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189276777 | ||||||||
| FaxNumber: | 3189276714 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 MORRIS CIR | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710402100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189276777 | ||||||||
| FaxNumber: | 3189276714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 10/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 018524 | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | 018524 | LA | N | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1358827 | 05 | LA | MEDICAID |