Provider Demographics
NPI:1114079597
Name:CLEMENTS, MELISSA K (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:K
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 WATERFORD BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-1162
Mailing Address - Country:US
Mailing Address - Phone:405-843-7401
Mailing Address - Fax:405-843-7607
Practice Address - Street 1:6301 WATERFORD BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-1162
Practice Address - Country:US
Practice Address - Phone:405-843-7401
Practice Address - Fax:405-843-7607
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14621174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD34505Medicare UPIN