Basic Information
| Provider Information | |||||||||
| NPI: | 1689960650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | CLAYTON | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3988 | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629023988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184575200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 117 E CLARK ST | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629462702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182528625 | ||||||||
| FaxNumber: | 6183514859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2011 | ||||||||
| LastUpdateDate: | 02/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 11016194A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036134206 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.