Provider Demographics
NPI:1497986731
Name:CLEMENTE, ETHEL GONZALES (MD)
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:GONZALES
Last Name:CLEMENTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9300 VALLEY CHILDRENS PL # SC05
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8761
Mailing Address - Country:US
Mailing Address - Phone:559-353-5700
Mailing Address - Fax:
Practice Address - Street 1:3525 PELANDALE AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9781
Practice Address - Country:US
Practice Address - Phone:559-572-3880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH098965208000000X
MS237112080P0205X
MI43011142642080P0205X
CAC1750832080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1497986731Medicaid
MS426812YJ5DMedicare PIN