Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | C39170 | CA |
N | 207PP0204X | Pediatric Emergency Physician | C39170 | CA |
N | 208000000X | Pediatrician | C39170 | CA |
NPI | 1730239542 |
---|---|
Provider Name | Charles T. Clemons |
First Address | Lafayette, CA 94549-4816 |
Second Address | Lafayette, CA 94549-4816 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/01/2007 |
Last Update Date | 26/02/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00C391700 | (05) | CA |
F16142 | (02) |