Provider Demographics
NPI:1669281549
Name:IKOME, CLARENCE SR
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:
Last Name:IKOME
Suffix:SR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 CHARLOTTE STREET
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740
Mailing Address - Country:US
Mailing Address - Phone:240-543-4629
Mailing Address - Fax:
Practice Address - Street 1:78 CHARLOTTE STREET
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740
Practice Address - Country:US
Practice Address - Phone:240-543-4629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-04
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty