1104093632 NPI number — DR. CLYDE FRANKLIN TRUAN III PH.D.

Table of content: DR. CLYDE FRANKLIN TRUAN III PH.D. (NPI 1104093632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104093632 NPI number — DR. CLYDE FRANKLIN TRUAN III PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRUAN
Provider First Name:
CLYDE
Provider Middle Name:
FRANKLIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
PH.D.
Provider Gender Code:
M

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:
1104093632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2465 DEMERE RD
Provider Second Line Business Mailing Address:
SUITE 209
Provider Business Mailing Address City Name:
ST SIMONS ISLAND
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31522-1630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-399-5414
Provider Business Mailing Address Fax Number:
912-267-7981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2465 DEMERE RD
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
ST SIMONS ISLAND
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31522-1630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-399-5414
Provider Business Practice Location Address Fax Number:
912-267-7981
Provider Enumeration Date:
05/14/2008

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: 103TC0700X , with the licence number:  000921 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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