1316931256 NPI number — DR. CLYDE R VARNER MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316931256 NPI number — DR. CLYDE R VARNER MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

VARNER

Provider First Name:

CLYDE

Provider Middle Name:

R

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1316931256

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

12/19/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 10880

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

PRESCOTT

Provider Business Mailing Address State Name:

AZ

Provider Business Mailing Address Postal Code:

86304-0880

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

928-759-5874

Provider Business Mailing Address Fax Number:

928-458-2039

Provider First Line Business Practice Location Address:

820 AINSWORTH DR

Provider Second Line Business Practice Location Address:

SUITE A

Provider Business Practice Location Address City Name:

PRESCOTT

Provider Business Practice Location Address State Name:

AZ

Provider Business Practice Location Address Postal Code:

86301-1613

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

928-778-0827

Provider Business Practice Location Address Fax Number:

928-778-5622

Provider Enumeration Date:

09/07/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2084V0102X , with the licence number:  42061 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084N0400X , with the licence number: 9981 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084N0400X , with the licence number: 08710R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084V0102X , with the licence number: 38948 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084N0400X , with the licence number: 42061 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0101241480 . This is a "LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
• Identifier: 201051630A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
• Identifier: 51545992 . This is a "BCBS- 3401 MEDICAL PK DR" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
• Identifier: 009913762 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
• Identifier: 51547299 . This is a "BCBS - 575 STANTON RD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
• Identifier: 09429053 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 101165 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".