Provider Demographics
NPI:1609099530
Name:CLEMMONS, MELONIE (OD)
Entity Type:Individual
Prefix:
First Name:MELONIE
Middle Name:
Last Name:CLEMMONS
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 1:64 WALNUT MOUNTAIN CT
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30536-2674
Mailing Address - Country:US
Mailing Address - Phone:706-635-3132
Mailing Address - Fax:
Practice Address - Street 1:60 OLD HIGHWAY 5 S
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-5436
Practice Address - Country:US
Practice Address - Phone:706-276-2000
Practice Address - Fax:706-276-2080
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2021-05-25
Deactivation Date:2021-05-02
Deactivation Code:
Reactivation Date:2021-05-25
Provider Licenses
StateLicense IDTaxonomies
GAOPT001550152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA910061011AMedicaid
GA910061011AMedicaid
GA41ZCFPKMedicare PIN
GAV00891Medicare UPIN
GAGRP6606Medicare Oscar/Certification