Healthcare Provider Details

I. General information

NPI: 1023246295
Provider Name (Legal Business Name): JESSE CLANTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEDICAL PARK RD STE 300
COLUMBIA SC
29203-6839
US

IV. Provider business mailing address

3110 MACCORKLE AVE SE
CHARLESTON WV
25304-1210
US

V. Phone/Fax

Practice location:
  • Phone: 803-545-5800
  • Fax: 803-929-0492
Mailing address:
  • Phone: 304-347-1297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number26438
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: