Provider Demographics
NPI:1255407086
Name:WHETMORE, CLAYTON EARL (DO)
Entity type:Individual
Prefix:
First Name:CLAYTON
Middle Name:EARL
Last Name:WHETMORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 N MISSOURI ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MO
Mailing Address - Zip Code:63552-2095
Mailing Address - Country:US
Mailing Address - Phone:660-385-8700
Mailing Address - Fax:
Practice Address - Street 1:1205 N MISSOURI ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-2095
Practice Address - Country:US
Practice Address - Phone:660-385-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004030585207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000012067OtherMEDICARE NON-RURAL HEALTH
MO263834OtherMEDICARE RURAL HEALTH
MO242072627Medicaid
MO591720800Medicaid
MO501720809Medicaid
MO263834OtherMEDICARE RURAL HEALTH