Healthcare Provider Details

I. General information

NPI: 1275615775
Provider Name (Legal Business Name): WANDA J SIMMONS CLEMMONS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6724 GLENKIRK RD
BALTIMORE MD
21239-1410
US

IV. Provider business mailing address

808 GLENEAGLES CT # 20069
TOWSON MD
21286-2205
US

V. Phone/Fax

Practice location:
  • Phone: 443-900-3184
  • Fax: 410-433-2015
Mailing address:
  • Phone: 443-900-3184
  • Fax: 512-559-7040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberD0035674
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberD0035674
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: