Provider Demographics
NPI:1962513523
Name:ABELLA, CLARENCE (MD)
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:
Last Name:ABELLA
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 1:1356 HICKORY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-3451
Mailing Address - Country:US
Mailing Address - Phone:815-462-7735
Mailing Address - Fax:
Practice Address - Street 1:1106 NEAL AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60433-2548
Practice Address - Country:US
Practice Address - Phone:815-727-8670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G04988Medicare UPIN