Healthcare Provider Details

I. General information

NPI: 1992707285
Provider Name (Legal Business Name): CLINTON FRANKLIN MERRILL JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 SHRINE CLUB RD
LANDER WY
82520-8501
US

IV. Provider business mailing address

15 SHRINE CLUB RD
LANDER WY
82520-8501
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-0324
  • Fax: 307-332-0382
Mailing address:
  • Phone: 307-332-0324
  • Fax: 307-332-0382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number3277A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: