Healthcare Provider Details

I. General information

NPI: 1013322080
Provider Name (Legal Business Name): CLAYTON LEWIS THELEMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2521 GLENN HENDREN DR STE 108
LIBERTY MO
64068
US

IV. Provider business mailing address

PO BOX 219672
KANSAS CITY MO
64121-9672
US

V. Phone/Fax

Practice location:
  • Phone: 816-781-3515
  • Fax: 816-781-3517
Mailing address:
  • Phone: 816-407-4555
  • Fax: 816-407-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number12506876
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2019014000
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: