Healthcare Provider Details

I. General information

NPI: 1962477695
Provider Name (Legal Business Name): CLYDE S MECKSTROTH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15590 MEADOW WOOD DR
WELLINGTON FL
33414-9009
US

IV. Provider business mailing address

5300 EAST AVE
WEST PALM BEACH FL
33407-2387
US

V. Phone/Fax

Practice location:
  • Phone: 561-793-0567
  • Fax: 561-863-2806
Mailing address:
  • Phone: 561-227-5270
  • Fax: 561-863-2806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOS5367
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: