1194831842 NPI number — CLYDE R WHITE DC

Table of content: CLYDE R WHITE DC (NPI 1194831842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194831842 NPI number — CLYDE R WHITE DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITE
Provider First Name:
CLYDE
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1194831842
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 RIVER SPRINGS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEGUIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78155-0179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-684-3200
Provider Business Mailing Address Fax Number:
830-557-6820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4411 WALZEM RD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78218-2020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-684-3200
Provider Business Practice Location Address Fax Number:
210-684-3200
Provider Enumeration Date:
08/22/2006

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: 111N00000X , with the licence number:  2154 , 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: P00080796 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00080796 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: D01016701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00JK40 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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