Healthcare Provider Details

I. General information

NPI: 1407597966
Provider Name (Legal Business Name): CLEMENT JOSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

MSC10 5610 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

12404 SIERRA GRANDE AVE NE
ALBUQUERQUE NM
87112-5841
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-4161
  • Fax:
Mailing address:
  • Phone: 505-977-3602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: