Healthcare Provider Details

I. General information

NPI: 1144224569
Provider Name (Legal Business Name): JOHN W CLOUSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5057 S GLENHAVEN AVE
SPRINGFIELD MO
65804-7800
US

IV. Provider business mailing address

5057 S GLENHAVEN AVE
SPRINGFIELD MO
65804-7800
US

V. Phone/Fax

Practice location:
  • Phone: 417-887-7914
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberR5B59
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberR5B59
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: