Healthcare Provider Details

I. General information

NPI: 1689171621
Provider Name (Legal Business Name): ANDREW R CLEMENTZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1863 MEMORIAL DR SE
ATLANTA GA
30317-2103
US

IV. Provider business mailing address

1220 CAROLINE ST NE STE A-230
ATLANTA GA
30307-2749
US

V. Phone/Fax

Practice location:
  • Phone: 470-717-0719
  • Fax:
Mailing address:
  • Phone: 678-710-3980
  • Fax: 404-778-6901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number83828
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: