Basic Information
Provider Information | |||||||||
NPI: | 1154736684 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLEMENT | ||||||||
FirstName: | CORY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.P.M. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1172 N MACLAY AVE | ||||||||
Address2: |   | ||||||||
City: | SAN FERNANDO | ||||||||
State: | CA | ||||||||
PostalCode: | 913401328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8188981388 | ||||||||
FaxNumber: | 8182709590 | ||||||||
Practice Location | |||||||||
Address1: | 1600 SAN FERNANDO RD | ||||||||
Address2: |   | ||||||||
City: | SAN FERNANDO | ||||||||
State: | CA | ||||||||
PostalCode: | 913403115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8183658086 | ||||||||
FaxNumber: | 8183656916 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2014 | ||||||||
LastUpdateDate: | 01/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 06/04/2018 | ||||||||
NPIReactivationDate: | 06/20/2018 | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | E5365 | CA | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.