Provider Demographics
NPI:1588645386
Name:CLEMENTE, MICHELLE DIZON (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIZON
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 1:863 BUTTNER PL
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-2406
Mailing Address - Country:US
Mailing Address - Phone:302-734-3331
Mailing Address - Fax:302-734-9908
Practice Address - Street 1:863 BUTTNER PL
Practice Address - Street 2:SUITE 103
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-2406
Practice Address - Country:US
Practice Address - Phone:302-734-3331
Practice Address - Fax:302-734-9908
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0007712208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE232158285OtherBCBS PROVIDER ID NUMBER