Healthcare Provider Details

I. General information

NPI: 1114556610
Provider Name (Legal Business Name): CLINTON MATTHEW GARRISON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N SENATE BLVD # AG012
INDIANAPOLIS IN
46202-1239
US

IV. Provider business mailing address

1701 N SENATE BLVD # AG012
INDIANAPOLIS IN
46202-1239
US

V. Phone/Fax

Practice location:
  • Phone: 317-962-5975
  • Fax:
Mailing address:
  • Phone: 317-962-5975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number02006780A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: