Provider Demographics
NPI:1700075595
Name:IDEHEN, CLEMENT ENORENSE (OD)
Entity Type:Individual
Prefix:DR
First Name:CLEMENT
Middle Name:ENORENSE
Last Name:IDEHEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5546 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-3554
Mailing Address - Country:US
Mailing Address - Phone:718-628-9200
Mailing Address - Fax:718-628-5600
Practice Address - Street 1:5546 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-3554
Practice Address - Country:US
Practice Address - Phone:718-628-9200
Practice Address - Fax:718-628-5600
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT006065152W00000X
NYVUT006065152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03424Medicare UPIN