Healthcare Provider Details

I. General information

NPI: 1457456584
Provider Name (Legal Business Name): CLINTON EARL PRESCOTT JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 COTTAGE AVE
MANTECA CA
95336-4942
US

IV. Provider business mailing address

296 COTTAGE AVE
MANTECA CA
95336-4942
US

V. Phone/Fax

Practice location:
  • Phone: 209-239-2901
  • Fax: 209-239-8662
Mailing address:
  • Phone: 209-239-2901
  • Fax: 209-239-8662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA25653
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: