Provider Demographics
NPI:1093744773
Name:CLEMENZ, LAYNE RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:LAYNE
Middle Name:RICHARD
Last Name:CLEMENZ
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 1:2720 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-4810
Mailing Address - Country:US
Mailing Address - Phone:803-791-2460
Mailing Address - Fax:803-791-2519
Practice Address - Street 1:508 HULON LANE
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169
Practice Address - Country:US
Practice Address - Phone:803-791-2460
Practice Address - Fax:803-791-2519
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC122812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC122815Medicaid
SCB917291557Medicare PIN
SC122815Medicaid