Provider Demographics
NPI:1366587040
Name:CLIFTON, CHARLES RUSSELL JR (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RUSSELL
Last Name:CLIFTON
Suffix:JR
Gender:M
Credentials:PHD
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Mailing Address - Street 1:2121 NW 40TH TER
Mailing Address - Street 2:SUITE B
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-5813
Mailing Address - Country:US
Mailing Address - Phone:352-336-2888
Mailing Address - Fax:352-371-1730
Practice Address - Street 1:2121 NW 40TH TERRACE
Practice Address - Street 2:SUITE B
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605
Practice Address - Country:US
Practice Address - Phone:352-336-2888
Practice Address - Fax:352-371-1730
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2011-12-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPY2731103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
75541Medicare ID - Type Unspecified
NPP000Medicare UPIN