Provider Demographics
NPI:1871561951
Name:CLINTON, MARIANNE (MD)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:CLINTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIANNE
Other - Middle Name:
Other - Last Name:CLINTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:280 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-4816
Mailing Address - Country:US
Mailing Address - Phone:212-227-8401
Mailing Address - Fax:212-227-8842
Practice Address - Street 1:1427 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-4202
Practice Address - Country:US
Practice Address - Phone:347-390-8706
Practice Address - Fax:347-396-9785
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29208207Q00000X
CAG50695207Q00000X
OR167056207Q00000X
NY298988-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR096511Medicaid
OR22959Medicaid
OR096511Medicaid
ORR0000WCJHTMedicare Oscar/Certification