Healthcare Provider Details

I. General information

NPI: 1982673562
Provider Name (Legal Business Name): CLYDE O. HURST JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 HIGHWAY 190 SUITE D-5
COVINGTON LA
70433-4956
US

IV. Provider business mailing address

5001 HIGHWAY 190 SUITE D-5
COVINGTON LA
70433-4930
US

V. Phone/Fax

Practice location:
  • Phone: 985-892-9505
  • Fax: 985-892-9505
Mailing address:
  • Phone: 985-892-9505
  • Fax: 985-892-9505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number017937
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: