Provider Demographics
NPI:1235217555
Name:CLEMENCE, ELLIOTT IRVING III (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:IRVING
Last Name:CLEMENCE
Suffix:III
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 1:7500 BARLITE BLVD STE 309
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78224-1361
Mailing Address - Country:US
Mailing Address - Phone:210-924-9000
Mailing Address - Fax:210-924-7300
Practice Address - Street 1:7500 BARLITE BLVD STE 309
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78224-1361
Practice Address - Country:US
Practice Address - Phone:210-924-9000
Practice Address - Fax:210-924-7300
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0004207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100345101Medicaid
TX0U58ROtherBLUECROSS BLUESHIELD
TXG07132Medicare UPIN
82390JMedicare PIN
TX0U58ROtherBLUECROSS BLUESHIELD