Provider Demographics
NPI:1043382344
Name:CLEMENTS, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:CLEMENTS
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:PO BOX 1384
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-7384
Mailing Address - Country:US
Mailing Address - Phone:860-644-9134
Mailing Address - Fax:860-644-9134
Practice Address - Street 1:100 BILTON RD
Practice Address - Street 2:
Practice Address - City:SOMERS
Practice Address - State:CT
Practice Address - Zip Code:06071
Practice Address - Country:US
Practice Address - Phone:860-566-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT037806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C29846Medicare UPIN