Basic Information
| Provider Information | |||||||||
| NPI: | 1497986731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMENTE | ||||||||
| FirstName: | ETHEL | ||||||||
| MiddleName: | GONZALES | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL # SC05 | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936368761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593535700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3525 PELANDALE AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953569781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595723880 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2009 | ||||||||
| LastUpdateDate: | 03/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 098965 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0205X | 23711 | MS | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 2080P0205X | 4301114264 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 2080P0205X | C175083 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 1497986731 | 05 | CA | MEDICAID |