Provider Demographics
NPI:1801115258
Name:CLEMENS, MICHAEL AVERY
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:AVERY
Last Name:CLEMENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8290 OLD COURTHOUSE RD STE D
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3837
Mailing Address - Country:US
Mailing Address - Phone:703-448-8818
Mailing Address - Fax:703-448-0468
Practice Address - Street 1:8290 OLD COURTHOUSE RD STE D
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3837
Practice Address - Country:US
Practice Address - Phone:703-448-8818
Practice Address - Fax:703-448-0468
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043568174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist