Provider Demographics
NPI:1225122435
Name:CLEMONS, AMY DAWN (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:DAWN
Last Name:CLEMONS
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:PO BOX 821
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-0821
Mailing Address - Country:US
Mailing Address - Phone:912-480-9444
Mailing Address - Fax:912-228-4654
Practice Address - Street 1:1555 BRAMPTON AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0856
Practice Address - Country:US
Practice Address - Phone:912-480-9444
Practice Address - Fax:912-228-4654
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2023-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057058207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA584491645AMedicaid
I62951Medicare UPIN
GA584491645AMedicaid