Provider Demographics
NPI:1710920632
Name:CLEMENTS, JOHN LARRY (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LARRY
Last Name:CLEMENTS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 S MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-1766
Mailing Address - Country:US
Mailing Address - Phone:540-725-1226
Mailing Address - Fax:540-857-5306
Practice Address - Street 1:390 S MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1766
Practice Address - Country:US
Practice Address - Phone:540-725-1226
Practice Address - Fax:540-857-5306
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000391213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1710920632OtherAETNA
VA1710920632OtherMAJESTACARE
VA1710920632OtherUNITED HEALTHCARE
VA1710920632OtherCIGNA
VA1710920632OtherBLACK LUNG
VA1710920632OtherANTHEM
VA1710920632OtherHEALTHKEEPERS
VA1710920632OtherHEALTHKEEPERS PLUS
VA1710920632Medicaid
VA1710920632OtherVA PREMIER
VA1710920632OtherOPTIMA HEALTH PLAN
VA1710920632OtherGATEWAY
VA540506332085OtherTRICARE/CHAMPUS
VA1710920632OtherSOUTHERN HEALTH/CARENET/CARELINK/COVENTRY
VA1710920632OtherUMWA
VA1710920632OtherVIRGINIA HEALTH NETWORK
VA1710920632OtherHUMANA MEDICARE
VA1710920632OtherINTOTAL
VAP00624452OtherRAILROAD MEDICARE
VA1710920632OtherUNITED HEALTHCARE
VA1710920632OtherBLACK LUNG