Provider Demographics
NPI:1275543175
Name:CLEMENTE V. ZULUETA, JR., MD, PLLC
Entity Type:Organization
Organization Name:CLEMENTE V. ZULUETA, JR., MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLEMENTE
Authorized Official - Middle Name:V
Authorized Official - Last Name:ZULUETA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:606-693-1078
Mailing Address - Street 1:PO BOX 908
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-0908
Mailing Address - Country:US
Mailing Address - Phone:606-693-1078
Mailing Address - Fax:606-693-1079
Practice Address - Street 1:95 JACKSON HTS
Practice Address - Street 2:STE 201
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-6500
Practice Address - Country:US
Practice Address - Phone:606-693-1078
Practice Address - Fax:606-693-1079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY31-000847Medicaid
KY31-000847Medicaid