Provider Demographics
NPI:1649448267
Name:CLEMETSON, CHARLES D (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
Last Name:CLEMETSON
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 1:39 FORESIDE RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04110-1405
Mailing Address - Country:US
Mailing Address - Phone:207-415-2700
Mailing Address - Fax:207-899-0138
Practice Address - Street 1:39 FORESIDE RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04110-1405
Practice Address - Country:US
Practice Address - Phone:207-415-2700
Practice Address - Fax:207-899-0138
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-17
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0138082084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry