Healthcare Provider Details

I. General information

NPI: 1144290602
Provider Name (Legal Business Name): ANGELA CLEMENTE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 OSAGE EXECUTIVE CIR
HOUSE SPRINGS MO
63051-1382
US

IV. Provider business mailing address

100 OSAGE EXECUTIVE CIR
HOUSE SPRINGS MO
63051-1382
US

V. Phone/Fax

Practice location:
  • Phone: 636-677-9977
  • Fax: 636-677-9179
Mailing address:
  • Phone: 636-677-9977
  • Fax: 636-677-9179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number113997
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: