Provider Demographics
NPI:1366896458
Name:ENOS, CLINTON
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:ENOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 FAIRFAX AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-2007
Mailing Address - Country:US
Mailing Address - Phone:757-446-5629
Mailing Address - Fax:757-446-6000
Practice Address - Street 1:721 FAIRFAX AVE STE 200
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-2007
Practice Address - Country:US
Practice Address - Phone:757-446-5629
Practice Address - Fax:757-446-6000
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2022-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME151678207N00000X
390200000X
VA0101275278207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110954500Medicaid