Provider Demographics
NPI:1922048214
Name:CLOUSE, SHIRLEY (MD)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:CLOUSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 BARBAROSSA LN
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-1221
Mailing Address - Country:US
Mailing Address - Phone:845-338-3737
Mailing Address - Fax:845-338-3939
Practice Address - Street 1:35 BARBAROSSA LN
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-1221
Practice Address - Country:US
Practice Address - Phone:845-338-3737
Practice Address - Fax:845-338-3939
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208517-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2473P1OtherEMPIRE BC/BS
NY2473P2OtherEMPIRE BC/BS
NY361509OtherMVP HEALTH PLAN
NY000498939006OtherBLUE SHIELD NORTHEASTERN
NY10057418OtherCDPHP
NY02209901Medicaid
NY087314OtherGHI HMO INSURANCE
NY10057418OtherCDPHP
NYH40129Medicare UPIN