=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578862959
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN B. CLEMMONS, JR., M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2011
-----------------------------------------------------
Last Update Date | 02/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1213 HERMANN DR STE 220
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77004-7009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-528-6562
-----------------------------------------------------
Fax | 713-528-1045
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1213 HERMANN DR STE 220
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77004-7009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-528-6562
-----------------------------------------------------
Fax | 713-528-1045
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | DR. JOHN CLEMMONS JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-528-6562
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | G0677
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------