Provider Demographics
NPI:1063690535
Name:NICODEMUS, CLARENCE L (PHD DO)
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:L
Last Name:NICODEMUS
Suffix:
Gender:M
Credentials:PHD DO
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-432-6144
Mailing Address - Fax:517-432-6150
Practice Address - Street 1:4660 S HAGADORN RD
Practice Address - Street 2:SUITE 500
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5376
Practice Address - Country:US
Practice Address - Phone:517-432-6144
Practice Address - Fax:517-432-6150
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101016107204D00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1063690535Medicaid