Provider Demographics
NPI:1871551747
Name:CLEMMENSEN, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CLEMMENSEN
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 1:1100 S CARSON ST
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89701-5232
Mailing Address - Country:US
Mailing Address - Phone:775-883-7811
Mailing Address - Fax:
Practice Address - Street 1:1100 S CARSON ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-5232
Practice Address - Country:US
Practice Address - Phone:775-883-7811
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3757207N00000X, 207ND0101X, 207ND0900X, 207NS0135X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Not Answered207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine