1669458113 NPI number — CLYDE MORRIS PENCE MD

Table of content: CLYDE MORRIS PENCE MD (NPI 1669458113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669458113 NPI number — CLYDE MORRIS PENCE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENCE
Provider First Name:
CLYDE
Provider Middle Name:
MORRIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1669458113
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14055 VALLEY VIEW LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-868-5351
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
512 CROFTON PARK LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKLIN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37069-6516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-218-3404
Provider Business Practice Location Address Fax Number:
850-474-8096
Provider Enumeration Date:
12/16/2005

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: 207RN0300X , with the licence number:  ME36307 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: MD0000057227 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009935449 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 17471 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5904025 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 065065000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com