Provider Demographics
NPI:1609879931
Name:CLEMONS, CAROL S (MD, PHD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:S
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 ASHLEY RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7229
Mailing Address - Country:US
Mailing Address - Phone:318-861-4009
Mailing Address - Fax:318-861-4080
Practice Address - Street 1:471 ASHLEY RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7229
Practice Address - Country:US
Practice Address - Phone:318-861-4009
Practice Address - Fax:318-861-4080
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16168207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAB63171Medicare UPIN
LA51568Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER