Provider Demographics
NPI:1437646791
Name:CLEMENTS, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CLEMENTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3507 32ND ST APT A3
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2748
Mailing Address - Country:US
Mailing Address - Phone:516-503-9146
Mailing Address - Fax:
Practice Address - Street 1:33 W 42ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-8005
Practice Address - Country:US
Practice Address - Phone:212-938-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-21
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008775152W00000X
390200000X
NYTUV008775-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program