MEDICARE: KELLY T CLOUSE 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
1	2084P0800X	Psychiatry Physician	ME110938	FL
2	2084P0800X	Psychiatry Physician	46974	WI

Other Identifiers

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

General Provider Information

NPI Number	:	1932104288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY T CLOUSE MD

Provider Business Mailing Address
First Line	:	2021 PROFESSIONAL CENTER DR STE 101
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-4461
Country	:	US
Telephone Number	:	904-213-9210
Fax Number	:	904-213-9211

Provider Business Practice Location Address
First Line	:	2021 PROFESSIONAL CENTER DR STE 101
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-4461
Country	:	US
Telephone Number	:	904-213-9210
Fax Number	:	904-213-9211

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	01/21/2022

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Directions to “ KELLY T CLOUSE MD” Practice Location

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