Healthcare Provider Details

I. General information

NPI: 1366440687
Provider Name (Legal Business Name): CLIFTON TATUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 01/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E GRAY ST
LOUISVILLE KY
40202-2012
US

IV. Provider business mailing address

234 E GRAY ST SUITE 850
LOUISVILLE KY
40202-1900
US

V. Phone/Fax

Practice location:
  • Phone: 502-629-7601
  • Fax:
Mailing address:
  • Phone: 502-585-1735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number26863
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: