Provider Demographics
NPI:1285676338
Name:CLEMENS, JOHN W (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:CLEMENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:W
Other - Last Name:CLEMENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1924 BALD HILL RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-3810
Mailing Address - Country:US
Mailing Address - Phone:573-634-7437
Mailing Address - Fax:573-761-6888
Practice Address - Street 1:2701 W EDGEWOOD DR
Practice Address - Street 2:SUITE 101
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5889
Practice Address - Country:US
Practice Address - Phone:573-634-5303
Practice Address - Fax:573-761-6888
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203831102Medicaid
MOG86854Medicare UPIN
MO203831102Medicaid