Provider Demographics
NPI:1972668796
Name:CLEMENTS, MICHAEL P (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:CLEMENTS
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 1:1701 SUDDERTH DR
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6114
Mailing Address - Country:US
Mailing Address - Phone:575-630-1055
Mailing Address - Fax:575-630-1066
Practice Address - Street 1:1701 SUDDERTH DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-7067
Practice Address - Country:US
Practice Address - Phone:575-630-1055
Practice Address - Fax:575-630-1066
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM96-218207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ0066Medicaid
NMQ0066Medicaid
NM$$$$$$$$$Medicare PIN