Provider Demographics
NPI:1174541874
Name:CLEMENSON, STEVEN GLENN (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:GLENN
Last Name:CLEMENSON
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 1:2226 HUALAPAI MOUNTAIN RD
Mailing Address - Street 2:STE 101
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-8374
Mailing Address - Country:US
Mailing Address - Phone:701-280-2033
Mailing Address - Fax:701-232-5578
Practice Address - Street 1:4450 31ST AVE S STE 102
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4557
Practice Address - Country:US
Practice Address - Phone:701-280-2033
Practice Address - Fax:701-232-5578
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29533207R00000X
AZ60970207R00000X
ND9791207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E02378Medicare UPIN