=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528621067
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLAYTON EUGENE KIBLER MD, MMS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2019
-----------------------------------------------------
Last Update Date | 07/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33608 ORTEGA HWY
-----------------------------------------------------
City | SAN JUAN CAPISTRANO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92675-2042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-642-4657
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1183 SABLE
-----------------------------------------------------
City | RANCHO SANTA MARGARITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92688-5589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-755-6203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | MD2023-0481
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------