Healthcare Provider Details

I. General information

NPI: 1487148177
Provider Name (Legal Business Name): CLAYTON FRANKLIN FUQUA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7050 AIR DEPOT BLVD BLDG 1094
TINKER AFB OK
73145-8716
US

IV. Provider business mailing address

7050 AIR DEPOT BLVD BLDG 1094
TINKER AFB OK
73145-8716
US

V. Phone/Fax

Practice location:
  • Phone: 405-582-6615
  • Fax:
Mailing address:
  • Phone: 405-582-6615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101267570
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: