Provider Demographics
NPI:1497755110
Name:CLEMENTE, THOMAS F (DPM INC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:F
Last Name:CLEMENTE
Suffix:
Gender:M
Credentials:DPM INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14600 SHERMAN WAY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405
Mailing Address - Country:US
Mailing Address - Phone:818-988-6880
Mailing Address - Fax:818-988-3289
Practice Address - Street 1:14600 SHERMAN WAY
Practice Address - Street 2:SUITE 210
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405
Practice Address - Country:US
Practice Address - Phone:818-988-6880
Practice Address - Fax:818-988-3289
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2604213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA953802534OtherBLUE CROSS
CA953802534OtherBLUE SHIELD
95-3802534OtherBX
CA000E26040Medicaid
95-3802534OtherBLUE SHIELD
CAE2604Medicare PIN
CA0816730001Medicare NSC
CA953802534OtherBLUE SHIELD