Healthcare Provider Details

I. General information

NPI: 1952760308
Provider Name (Legal Business Name): CLOVIS DERMATOLOGY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2016
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 W HERNDON AVE
CLOVIS CA
93612-0204
US

IV. Provider business mailing address

275 W HERNDON AVE
CLOVIS CA
93612-0204
US

V. Phone/Fax

Practice location:
  • Phone: 559-321-4255
  • Fax:
Mailing address:
  • Phone: 559-321-4255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RAYMOND KIDWELL
Title or Position: CEO
Credential: M.D.
Phone: 559-298-7220