1568480705 NPI number — DR. CLYDE WILTON SIMMONS JR. M.D.

Table of content: DR. CLYDE WILTON SIMMONS JR. M.D. (NPI 1568480705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568480705 NPI number — DR. CLYDE WILTON SIMMONS JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMMONS
Provider First Name:
CLYDE
Provider Middle Name:
WILTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIMMONS
Provider Other First Name:
C
Provider Other Middle Name:
WILTON
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1568480705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
902 FROSTWOOD DR
Provider Second Line Business Mailing Address:
SUITE 244
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77024-2420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-932-6467
Provider Business Mailing Address Fax Number:
713-932-0647

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
902 FROSTWOOD DR
Provider Second Line Business Practice Location Address:
SUITE 244
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77024-2420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-932-6467
Provider Business Practice Location Address Fax Number:
713-932-0647
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  D7303 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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