Provider Demographics
NPI:1730239542
Name:CLEMONS, CHARLES T (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:T
Last Name:CLEMONS
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 1:926 RAINTREE PL
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-4816
Mailing Address - Country:US
Mailing Address - Phone:925-942-0451
Mailing Address - Fax:
Practice Address - Street 1:926 RAINTREE PL
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-4816
Practice Address - Country:US
Practice Address - Phone:925-942-0451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39170207P00000X, 207PP0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C391700Medicaid
F16142Medicare UPIN
CA00C391700Medicaid