Healthcare Provider Details

I. General information

NPI: 1922064591
Provider Name (Legal Business Name): CLIFTON STORY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 HIGHLAND WAY STE 103
MADISON MS
39110-6930
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-4750
  • Fax:
Mailing address:
  • Phone: 601-200-4750
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15085
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: