Provider Demographics
NPI:1871786707
Name:CLEMENTE, DONALD MICHAEL JR
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:MICHAEL
Last Name:CLEMENTE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2183 NEWBURGH DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-2524
Mailing Address - Country:US
Mailing Address - Phone:248-528-2599
Mailing Address - Fax:248-528-2599
Practice Address - Street 1:2183 NEWBURGH DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-2524
Practice Address - Country:US
Practice Address - Phone:248-528-2599
Practice Address - Fax:248-528-2599
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001978213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4467304Medicaid
MI4856352060OtherBCBS OF MICHIGAN
MI0N63700Medicare PIN
MI4856352060OtherBCBS OF MICHIGAN