Provider Demographics
NPI:1053405654
Name:CLEMENTE, RODERICK JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:JOHN
Last Name:CLEMENTE
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 1:96 GATES AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2501
Mailing Address - Country:US
Mailing Address - Phone:973-744-3166
Mailing Address - Fax:973-744-3199
Practice Address - Street 1:96 GATES AVENUE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042
Practice Address - Country:US
Practice Address - Phone:973-744-3166
Practice Address - Fax:973-744-3199
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04150100207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ582676791OtherTAX ID#
NJ542413SN2Medicare ID - Type Unspecified
NJC59724Medicare UPIN