Provider Demographics
NPI:1659438455
Name:CLEMENS, DALE S
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:S
Last Name:CLEMENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 FRANKLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-1614
Mailing Address - Country:US
Mailing Address - Phone:315-446-1288
Mailing Address - Fax:315-463-2210
Practice Address - Street 1:824 FRANKLIN PARK DR
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-1614
Practice Address - Country:US
Practice Address - Phone:315-446-1288
Practice Address - Fax:315-463-2210
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC006828156FC0801X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC006828OtherOPHTHALMIC DISPENSING LIC
NYNY6828OtherEYEMED PROVIDER NUMBER