Healthcare Provider Details
I. General information
NPI: 1700802634
Provider Name (Legal Business Name): DAVID J CLUTTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 07/14/2006
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
1702 UNIVERSITY DR S
FARGO ND
58103-4940
US
IV. Provider business mailing address
PO BOX 6001
FARGO ND
58108-6001
US
V. Phone/Fax
- Phone: 701-364-3300
- Fax: 701-364-8906
- Phone: 701-364-3300
- Fax: 701-364-8906
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 208000000X |
| Taxonomy | Pediatrics Physician |
| License Number | 9323 |
| License Number State | ND |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 208000000X |
| Taxonomy | Pediatrics Physician |
| License Number | 45703 |
| License Number State | MN |
| # 3 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 208000000X |
| Taxonomy | Pediatrics Physician |
| License Number | 5340 |
| License Number State | ND |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 2346 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | NDBS # |
| # 2 | |
| Identifier | 676556 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | AMERICA'S PPO/ARAZ # |
| # 3 | |
| Identifier | 9601 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | SIOUX VALLEY # |
| # 4 | |
| Identifier | 28732CL |
| Identifier Type | OTHER |
| Identifier State | MN |
| Identifier Issuer | MNBS # |
| # 5 | |
| Identifier | DA9011015522 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | PREFERRED ONE # |
| # 6 | |
| Identifier | 15305 |
| Identifier Type | MEDICAID |
| Identifier State | ND |
| Identifier Issuer | |
| # 7 | |
| Identifier | 27359CL |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | MNBS # |
| # 8 | |
| Identifier | HP19524 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | HEALTHPARTNERS # |
| # 9 | |
| Identifier | ND100001 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | LHS # |
| # 10 | |
| Identifier | 1201179 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | MEDICA # |
| # 11 | |
| Identifier | 1201796 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | MEDICA # |
| # 12 | |
| Identifier | 10424 |
| Identifier Type | OTHER |
| Identifier State | MN |
| Identifier Issuer | MNBS # |
| # 13 | |
| Identifier | 142003 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | UCARE # |
| # 14 | |
| Identifier | 49788CL |
| Identifier Type | OTHER |
| Identifier State | MN |
| Identifier Issuer | MNBS # |
| # 15 | |
| Identifier | 694882100 |
| Identifier Type | MEDICAID |
| Identifier State | ND |
| Identifier Issuer | |
| # 16 | |
| Identifier | 92799CL |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | MNBS # |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
