Healthcare Provider Details

I. General information

NPI: 1922111657
Provider Name (Legal Business Name): CLINT ANTHONY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

IV. Provider business mailing address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

V. Phone/Fax

Practice location:
  • Phone: 602-222-2752
  • Fax:
Mailing address:
  • Phone: 602-222-2752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG85401
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.151063
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: