Provider Demographics
NPI:1396833752
Name:SAN CLEMENTE, ADELE M (OD)
Entity Type:Individual
Prefix:DR
First Name:ADELE
Middle Name:M
Last Name:SAN CLEMENTE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184
Mailing Address - Country:US
Mailing Address - Phone:781-848-7977
Mailing Address - Fax:781-848-7977
Practice Address - Street 1:823 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184
Practice Address - Country:US
Practice Address - Phone:781-848-7977
Practice Address - Fax:781-848-7977
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2660152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
W15298OtherBX
MA0331139Medicaid
MA0331139Medicaid