Provider Demographics
NPI:1457394611
Name:CLEMONS, MARK P (MD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:P
Last Name:CLEMONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6616 KIRBY CENTER CV
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115
Mailing Address - Country:US
Mailing Address - Phone:901-363-8400
Mailing Address - Fax:901-363-8644
Practice Address - Street 1:6616 KIRBY CENTER COVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115
Practice Address - Country:US
Practice Address - Phone:901-363-8400
Practice Address - Fax:901-363-8644
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000016200207Y00000X
ARN7584207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3013157Medicaid
AR111549001Medicaid
TN0917170001Medicare NSC
AR0917170001Medicare NSC
AR111549001Medicaid
A97714Medicare UPIN
TN3013157Medicaid