Healthcare Provider Details

I. General information

NPI: 1629126149
Provider Name (Legal Business Name): KELLY M CLAYTON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 03/14/2021
Certification Date: 03/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 JOE DIMAGGIO DR
HOLLYWOOD FL
33021-5402
US

IV. Provider business mailing address

1005 JOE DIMAGGIO DR
HOLLYWOOD FL
33021-5402
US

V. Phone/Fax

Practice location:
  • Phone: 954-265-3482
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.29481
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD.29481
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberTRN10591
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberME112508
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: