Healthcare Provider Details

I. General information

NPI: 1912528928
Provider Name (Legal Business Name): CLEMENT PODIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 HILL RD STE E
NOVATO CA
94947-4338
US

IV. Provider business mailing address

1615 HILL RD STE E
NOVATO CA
94947-4338
US

V. Phone/Fax

Practice location:
  • Phone: 415-898-4828
  • Fax: 415-898-4878
Mailing address:
  • Phone: 415-898-4828
  • Fax: 415-898-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEILA OSTOVER-KERMANI
Title or Position: OWNER
Credential: DPM
Phone: 415-898-4828