Provider Demographics
NPI:1639141666
Name:CLONTZ, TED (MD)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:
Last Name:CLONTZ
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:8401 MEDICAL PLAZA DR
Mailing Address - Street 2:STE 365
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-8797
Mailing Address - Country:US
Mailing Address - Phone:704-944-0975
Mailing Address - Fax:704-944-3699
Practice Address - Street 1:8401 MEDICAL PLAZA DR
Practice Address - Street 2:STE 365
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-8797
Practice Address - Country:US
Practice Address - Phone:704-944-0975
Practice Address - Fax:704-944-3699
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2015-03-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC1981-25563207Q00000X
NC25563207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN25563Medicaid
NC891232HMedicaid
NC891232HMedicaid
NCC83273Medicare UPIN