=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912529090
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLAYTON PRESTON DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2020
-----------------------------------------------------
Last Update Date | 07/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 HARMONY PARK CIR STE 100
-----------------------------------------------------
City | HOT SPRINGS NATIONAL PARK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71913-5404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-881-4988
-----------------------------------------------------
Fax | 501-881-4755
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 HARMONY PARK CIR STE 100
-----------------------------------------------------
City | HOT SPRINGS NATIONAL PARK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71913-5404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-881-4988
-----------------------------------------------------
Fax | 501-881-4755
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | E-16904
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------