Healthcare Provider Details

I. General information

NPI: 1447631536
Provider Name (Legal Business Name): CLINTON ALEXANDER VESELIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

3401 N BROAD ST DEPT OF
PHILADELPHIA PA
19140-5103
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-2564
  • Fax:
Mailing address:
  • Phone: 215-762-8220
  • Fax: 215-762-1470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMT209701
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMT209701
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberMT209701
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: