1083789002 NPI number — TERRY A. CLYBURN, M. D., P.A.

Table of content: (NPI 1083789002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083789002 NPI number — TERRY A. CLYBURN, M. D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERRY A. CLYBURN, M. D., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083789002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4356
Provider Second Line Business Mailing Address:
DEPT. 967
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77210-4356
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-357-4752
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5420 WEST LOOP S
Provider Second Line Business Practice Location Address:
SUITE 2400
Provider Business Practice Location Address City Name:
BELLAIRE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77401-2107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-357-4752
Provider Business Practice Location Address Fax Number:
832-213-0308
Provider Enumeration Date:
11/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLYBURN
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
713-357-4752

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  F3846 , 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)

  • Identifier: 0085PA . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com