Provider Demographics
NPI:1659439107
Name:NWOSU, CLEMENT C (MD)
Entity Type:Individual
Prefix:
First Name:CLEMENT
Middle Name:C
Last Name:NWOSU
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 1:1122 GRAY HWY
Mailing Address - Street 2:STE 4
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-1869
Mailing Address - Country:US
Mailing Address - Phone:478-745-8309
Mailing Address - Fax:478-745-8364
Practice Address - Street 1:1122 GRAY HWY
Practice Address - Street 2:STE 4
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-1869
Practice Address - Country:US
Practice Address - Phone:478-745-8309
Practice Address - Fax:478-745-8364
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033504207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000442516BMedicaid
GA000442516AMedicaid
GA000442516AMedicaid
202I390261Medicare PIN