Provider Demographics
NPI:1609828490
Name:KLEMENTAVICIUS, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:KLEMENTAVICIUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 BAY CLIFFS RD
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4805
Mailing Address - Country:US
Mailing Address - Phone:850-934-4107
Mailing Address - Fax:850-934-4107
Practice Address - Street 1:617 BAY CLIFFS RD
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4805
Practice Address - Country:US
Practice Address - Phone:850-934-4107
Practice Address - Fax:850-934-4107
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77791207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46336OtherBCBS
AL59169917OtherBCBS
AL009984555Medicaid
FL256621400Medicaid
P00134526OtherPALMETTO GBA-RR MEDICARE
FL46336OtherBCBS
P00134526OtherPALMETTO GBA-RR MEDICARE