Provider Demographics
NPI:1740282417
Name:CLEMENT, JOHN KEVIN (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KEVIN
Last Name:CLEMENT
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 1:15 OLD STAGE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-3078
Mailing Address - Country:US
Mailing Address - Phone:423-639-8856
Mailing Address - Fax:423-639-8227
Practice Address - Street 1:15 OLD STAGE RD
Practice Address - Street 2:SUITE A
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-3078
Practice Address - Country:US
Practice Address - Phone:423-639-8856
Practice Address - Fax:423-639-8227
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT 1457152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4085057OtherBLUCROSS BLUESHIELD OF TN
TN3946021Medicaid
TN3946021Medicaid
TN3946021Medicare ID - Type UnspecifiedCIGNA MEDICARE
TN4085057OtherBLUCROSS BLUESHIELD OF TN