Basic Information
Provider Information | |||||||||
NPI: | 1932197365 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCLINTON | ||||||||
FirstName: | CEDRIC | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2500 W UTOPIA RD | ||||||||
Address2: | STE. 100 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850274171 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022146148 | ||||||||
FaxNumber: | 6022146149 | ||||||||
Practice Location | |||||||||
Address1: | 18404 N TATUM BLVD | ||||||||
Address2: | SUITE 101 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850321510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029921900 | ||||||||
FaxNumber: | 6024857450 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2005 | ||||||||
LastUpdateDate: | 09/25/2013 | ||||||||
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 | 207Q00000X | 12711 | AZ | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1070241 | 01 | AZ | CIGNA | OTHER | 4071662 | 01 | AZ | AETNA | OTHER | 1Z4543 | 01 | AZ | HEALTHNET | OTHER | 223975 | 05 | AZ |   | MEDICAID | AZ0805130 | 01 | AZ | BLUE CROSS BLUE SHIELD | OTHER | 378583200 | 01 | AZ | DEPT OF LABOR | OTHER | 81952 | 01 | AZ | MAYO | OTHER | 01-00254 | 01 | AS | UNITED HEALTHCARE | OTHER | 73521 | 01 | AZ | FIRST HEALTH | OTHER | 080100696 | 01 | AZ | RAILROAD MEDICARE | OTHER | 5027857 | 01 | AZ | CCN | OTHER |