MEDICARE: DR. TED CLONTZ M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	1981-25563	NC
2	207Q00000X	Family Medicine Physician	25563	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639141666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TED CLONTZ M.D.

Provider Business Mailing Address
First Line	:	8401 MEDICAL PLAZA DR
Second Line	:	STE 365
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-8797
Country	:	US
Telephone Number	:	704-944-0975
Fax Number	:	704-944-3699

Provider Business Practice Location Address
First Line	:	8401 MEDICAL PLAZA DR
Second Line	:	STE 365
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-8797
Country	:	US
Telephone Number	:	704-944-0975
Fax Number	:	704-944-3699

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	03/10/2015

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Directions to “ DR. TED CLONTZ M.D.” Practice Location

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