Provider Demographics
NPI:1871536755
Name:CLEMONS, BRUCE D (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:CLEMONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746550
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6550
Mailing Address - Country:US
Mailing Address - Phone:888-236-2263
Mailing Address - Fax:844-307-8606
Practice Address - Street 1:2250 IVY ROAD
Practice Address - Street 2:STE 200
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4977
Practice Address - Country:US
Practice Address - Phone:434-654-4550
Practice Address - Fax:844-307-8606
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101057895207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00466759Medicare PIN
VA00X569M02Medicare PIN
I05590Medicare UPIN