Basic Information
| Provider Information | |||||||||
| NPI: | 1578529327 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CLIFTON | ||||||||
| MiddleName: | DELOS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 247 | ||||||||
| Address2: | |||||||||
| City: | NORTH VASSALBORO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049620247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078736173 | ||||||||
| FaxNumber: | 2078734514 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | VASSALBORO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049893107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078736173 | ||||||||
| FaxNumber: | 2078734514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 01/12/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 011712 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000927 | 01 | ME | ANTHEM | OTHER | 1041270 | 01 | AETNA HMO | OTHER | 110084669 | 01 | RAILROAD MEDICARE | OTHER | 5201627 | 01 | AETNA NON-HMO | OTHER | D78788 | 01 | HARVARD PILGRIM | OTHER |