Provider Demographics
NPI:1487711909
Name:BAXTER, CLARKE WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:CLARKE
Middle Name:WILLIAM
Last Name:BAXTER
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 1:4760 RED BANK RD STE 104
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-1549
Mailing Address - Country:US
Mailing Address - Phone:513-271-4488
Mailing Address - Fax:513-271-4737
Practice Address - Street 1:45 HERRICK RD
Practice Address - Street 2:
Practice Address - City:SOUTHWEST HARBOR
Practice Address - State:ME
Practice Address - Zip Code:04679-4433
Practice Address - Country:US
Practice Address - Phone:207-244-5513
Practice Address - Fax:207-664-5515
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053662207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0687501Medicaid
BA0610272Medicare ID - Type Unspecified
OH0687501Medicaid