Healthcare Provider Details

I. General information

NPI: 1932166485
Provider Name (Legal Business Name): CLIFFORD CARL DOUGLAS MD, PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 BROCKTON AVE STE 175
RIVERSIDE CA
92501-4020
US

IV. Provider business mailing address

PO BOX 743111
ATLANTA GA
30374-3111
US

V. Phone/Fax

Practice location:
  • Phone: 951-786-5550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberG70288
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: