Healthcare Provider Details

I. General information

NPI: 1245230705
Provider Name (Legal Business Name): HOMER CLARK HYDE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2005
Last Update Date: 08/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 W MEMORIAL RD SUITE 422
OKLAHOMA CITY OK
73120-8366
US

IV. Provider business mailing address

4140 W MEMORIAL RD SUITE 422
OKLAHOMA CITY OK
73120-8366
US

V. Phone/Fax

Practice location:
  • Phone: 405-751-0051
  • Fax: 405-751-0051
Mailing address:
  • Phone: 405-751-0051
  • Fax: 405-751-0051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number8687
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: