Healthcare Provider Details

I. General information

NPI: 1801985197
Provider Name (Legal Business Name): CLEMENT E TAGOE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MMC - DEPT. OF MEDICINE 3400 BAINBRIDGE AVENUE
BRONX NY
10467
US

IV. Provider business mailing address

6710C 190TH LN APT. 3C
FRESH MEADOWS NY
11365-3730
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-7762
  • Fax: 718-231-0293
Mailing address:
  • Phone: 718-920-7762
  • Fax: 718-515-6103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number230072
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: