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NPI Code Detail

MEDICARE: CHARLES MANLEY CLODFELTER JR. MD

MEDICARE: CHARLES MANLEY CLODFELTER JR. MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207P00000XEmergency Medicine PhysicianME0071159FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
232302OTHERFLBCBS

General Provider Information

NPI Number : 1891774188
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHARLES MANLEY CLODFELTER JR. MD
Provider Business Mailing Address
First Line : PO BOX 2400
Second Line :
City : MELBOURNE
State : FL
Zip : 32902-2400
Country : US
Telephone Number : 321-837-3820
Fax Number : 321-837-3654
Provider Business Practice Location Address
First Line : 701 W COCOA BEACH CSWY
Second Line :
City : COCOA BEACH
State : FL
Zip : 32931-3585
Country : US
Telephone Number : 321-799-7111
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/13/2006
Last Update Date : 09/11/2014

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