Provider Demographics
NPI:1346337847
Name:CLEMENTS, JOHN K (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:K
Last Name:CLEMENTS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 S BEVERLY ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4131
Mailing Address - Country:US
Mailing Address - Phone:307-237-6025
Mailing Address - Fax:307-237-6025
Practice Address - Street 1:1421 S BEVERLY ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4131
Practice Address - Country:US
Practice Address - Phone:307-237-6025
Practice Address - Fax:307-237-6025
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY126T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY104051100Medicaid
WY4590842Medicare ID - Type Unspecified
WY104051100Medicaid