Provider Demographics
NPI:1902089246
Name:CLINTON A NETHERLAND, MD APMC
Entity Type:Organization
Organization Name:CLINTON A NETHERLAND, MD APMC
Other - Org Name:CLINTON A NETHERLAND, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:A
Authorized Official - Last Name:NETHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-556-3333
Mailing Address - Street 1:510 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-5033
Mailing Address - Country:US
Mailing Address - Phone:318-556-3333
Mailing Address - Fax:318-283-5141
Practice Address - Street 1:510 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-5033
Practice Address - Country:US
Practice Address - Phone:318-556-3333
Practice Address - Fax:318-283-5141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1104108Medicaid
LAG78317Medicare UPIN