Provider Demographics
NPI:1336182419
Name:CLEMENS, JONATHAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:L
Last Name:CLEMENS
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 1:315 N CALVERT ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-3611
Mailing Address - Country:US
Mailing Address - Phone:410-500-5597
Mailing Address - Fax:410-659-5691
Practice Address - Street 1:315 N CALVERT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-3611
Practice Address - Country:US
Practice Address - Phone:410-500-5597
Practice Address - Fax:410-659-5691
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD45302208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD131211100Medicaid
MD131211100Medicaid
C34452Medicare UPIN