Provider Demographics
NPI:1104340306
Name:ODAMTTEN, CLEMENTINE S (NP)
Entity type:Individual
Prefix:
First Name:CLEMENTINE
Middle Name:S
Last Name:ODAMTTEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 SHAUGHNESSY DR
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-5474
Mailing Address - Country:US
Mailing Address - Phone:571-524-6265
Mailing Address - Fax:
Practice Address - Street 1:2498 STEVENS CREEK BLVD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1652
Practice Address - Country:US
Practice Address - Phone:408-998-5400
Practice Address - Fax:408-998-5414
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006909207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine