1710920632 NPI number — JOHN LARRY CLEMENTS D.P.M.

Table of content: JOHN LARRY CLEMENTS D.P.M. (NPI 1710920632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710920632 NPI number — JOHN LARRY CLEMENTS D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEMENTS
Provider First Name:
JOHN
Provider Middle Name:
LARRY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710920632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
390 S MAIN ST
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
ROCKY MOUNT
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24151-1766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-725-1226
Provider Business Mailing Address Fax Number:
540-857-5306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
390 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
ROCKY MOUNT
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24151-1766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-725-1226
Provider Business Practice Location Address Fax Number:
540-857-5306
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  0103000391 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1710920632 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 . This is a "MAJESTACARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 . This is a "BLACK LUNG" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 . This is a "HEALTHKEEPERS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 . This is a "HEALTHKEEPERS PLUS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1710920632 . This is a "VA PREMIER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 . This is a "OPTIMA HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 . This is a "GATEWAY" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 540506332085 . This is a "TRICARE/CHAMPUS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 . This is a "SOUTHERN HEALTH/CARENET/CARELINK/COVENTRY" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 . This is a "UMWA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 . This is a "VIRGINIA HEALTH NETWORK" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 . This is a "HUMANA MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710920632 . This is a "INTOTAL" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00624452 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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