Provider Demographics
NPI:1023246295
Name:CLANTON, JESSE (MD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:CLANTON
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 1:3110 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1210
Mailing Address - Country:US
Mailing Address - Phone:304-347-1297
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL PARK RD STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6839
Practice Address - Country:US
Practice Address - Phone:803-545-5800
Practice Address - Fax:803-929-0492
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
WV26438208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program