Provider Demographics
NPI:1679614135
Name:CLEMMER, VIRGINIA B (MD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:B
Last Name:CLEMMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-1401
Mailing Address - Country:US
Mailing Address - Phone:302-658-4200
Mailing Address - Fax:302-658-4844
Practice Address - Street 1:2401 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-1401
Practice Address - Country:US
Practice Address - Phone:302-658-4200
Practice Address - Fax:302-658-4844
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0001875208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000013301Medicaid
DE071641Medicare ID - Type Unspecified
DE0000013301Medicaid