Provider Demographics
NPI:1255331351
Name:CLEMENTS, MACK H (MD)
Entity Type:Individual
Prefix:DR
First Name:MACK
Middle Name:H
Last Name:CLEMENTS
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 516
Mailing Address - Street 2:
Mailing Address - City:PINE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:31822-0516
Mailing Address - Country:US
Mailing Address - Phone:706-663-2574
Mailing Address - Fax:706-663-5954
Practice Address - Street 1:211 EAST BROAD ST
Practice Address - Street 2:
Practice Address - City:PINE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:31822-0516
Practice Address - Country:US
Practice Address - Phone:706-663-2574
Practice Address - Fax:706-663-5954
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11304208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00070452AMedicaid
GA00070452BMedicaid
GA00070452AMedicaid