Provider Demographics
NPI:1225163454
Name:CLEMMONS, ANTON M (MD)
Entity Type:Individual
Prefix:MR
First Name:ANTON
Middle Name:M
Last Name:CLEMMONS
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 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-4700
Mailing Address - Fax:941-917-4710
Practice Address - Street 1:929 S TAMIAMI TRL
Practice Address - Street 2:SUITE 101
Practice Address - City:OSPREY
Practice Address - State:FL
Practice Address - Zip Code:34229-9239
Practice Address - Country:US
Practice Address - Phone:941-917-4700
Practice Address - Fax:941-917-4710
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR1471207P00000X, 207R00000X
MO2015002903207R00000X, 208M00000X
KY42332207R00000X
FLME104483207R00000X, 208000000X
SC37428207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100064660Medicaid
SC374286Medicaid
FL145Z3OtherBCBS