Healthcare Provider Details

I. General information

NPI: 1427436088
Provider Name (Legal Business Name): ROBERT CLENDENIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2015
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

432 N BROADWAY AVE
SHAWNEE OK
74801-6922
US

IV. Provider business mailing address

93 S JACKSON ST # 98961
SEATTLE WA
98104-2818
US

V. Phone/Fax

Practice location:
  • Phone: 405-562-8380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number10884
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberC36830
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberC36830
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number21634
License Number StatePR
# 5
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number10884
License Number StateOK
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number21634
License Number StatePR
# 7
Primary TaxonomyN
Taxonomy Code2084P0301X
TaxonomyBrain Injury Medicine (Psychiatry & Neurology) Physician
License Number10884
License Number StateOK
# 8
Primary TaxonomyN
Taxonomy Code2084P0301X
TaxonomyBrain Injury Medicine (Psychiatry & Neurology) Physician
License NumberC36830
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code2084P0301X
TaxonomyBrain Injury Medicine (Psychiatry & Neurology) Physician
License Number21634
License Number StatePR
# 10
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number10884
License Number StateOK
# 11
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC36830
License Number StateCA
# 12
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number21634
License Number StatePR
# 13
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number10884
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: