Healthcare Provider Details

I. General information

NPI: 1750431250
Provider Name (Legal Business Name): JOHN L CLOTHIER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 CIVIC CENTER DR STE 206
SAN RAFAEL CA
94903-5233
US

IV. Provider business mailing address

4000 CIVIC CENTER DR STE 206
SAN RAFAEL CA
94903-5233
US

V. Phone/Fax

Practice location:
  • Phone: 415-925-8865
  • Fax: 415-446-0134
Mailing address:
  • Phone: 415-947-3096
  • Fax: 415-947-3094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberG81579
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG81579
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: