Provider Demographics
NPI:1841488905
Name:CLOCKER, CANDACE RENEE (MD)
Entity type:Individual
Prefix:DR
First Name:CANDACE
Middle Name:RENEE
Last Name:CLOCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 WILBORN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1628
Mailing Address - Country:US
Mailing Address - Phone:434-517-8022
Mailing Address - Fax:434-517-8370
Practice Address - Street 1:2100 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1628
Practice Address - Country:US
Practice Address - Phone:434-517-8022
Practice Address - Fax:434-517-8370
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-12
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01833208000000X
SC33110261QP2300X
VA0101261852208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC33110OtherLICENSE NUMBER