Provider Demographics
NPI:1689171621
Name:CLEMENTZ, ANDREW R (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:R
Last Name:CLEMENTZ
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 1:1220 CAROLINE ST NE STE A-230
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-2749
Mailing Address - Country:US
Mailing Address - Phone:678-710-3980
Mailing Address - Fax:404-778-6901
Practice Address - Street 1:1863 MEMORIAL DR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30317-2103
Practice Address - Country:US
Practice Address - Phone:470-717-0719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA83828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program