Healthcare Provider Details

I. General information

NPI: 1336182419
Provider Name (Legal Business Name): JONATHAN L CLEMENS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 03/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N CALVERT ST
BALTIMORE MD
21202-3611
US

IV. Provider business mailing address

315 N CALVERT ST
BALTIMORE MD
21202-3611
US

V. Phone/Fax

Practice location:
  • Phone: 410-500-5597
  • Fax: 410-659-5691
Mailing address:
  • Phone: 410-500-5597
  • Fax: 410-659-5691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD45302
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: