Provider Demographics
NPI:1902162076
Name:WARREN, CLINTON CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:CHARLES
Last Name:WARREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5017 GREEN BAY RD STE 148
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1782
Mailing Address - Country:US
Mailing Address - Phone:262-420-5888
Mailing Address - Fax:262-420-5889
Practice Address - Street 1:5017 GREEN BAY RD STE 148
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1782
Practice Address - Country:US
Practice Address - Phone:262-420-5888
Practice Address - Fax:262-420-5888
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI61666-20207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1902162076Medicaid