Provider Demographics
NPI:1134250921
Name:PARDALES, CLEMON (DO)
Entity type:Individual
Prefix:
First Name:CLEMON
Middle Name:
Last Name:PARDALES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:UNION LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48387-0609
Mailing Address - Country:US
Mailing Address - Phone:248-366-9504
Mailing Address - Fax:
Practice Address - Street 1:2775 BLAKE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-8838
Practice Address - Country:US
Practice Address - Phone:517-787-2906
Practice Address - Fax:517-787-3039
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101005389207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7891257OtherAETNA
MI7891257OtherAETNA
MIP00228743Medicare ID - Type UnspecifiedRAILROAD