Healthcare Provider Details

I. General information

NPI: 1679737506
Provider Name (Legal Business Name): STACY CLINTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST FL 3
LUBBOCK TX
79430
US

IV. Provider business mailing address

PO BOX 5865
LUBBOCK TX
79408-5865
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-7335
  • Fax: 806-743-4073
Mailing address:
  • Phone: 806-743-2898
  • Fax: 806-743-2787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN8632
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: