Healthcare Provider Details

I. General information

NPI: 1942288394
Provider Name (Legal Business Name): CLYDE LELAND COREY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 GRAHAM DR
TOMBALL TX
77375-6408
US

IV. Provider business mailing address

919 GRAHAM DR
TOMBALL TX
77375-6408
US

V. Phone/Fax

Practice location:
  • Phone: 281-516-6530
  • Fax: 281-290-9824
Mailing address:
  • Phone: 281-516-6530
  • Fax: 281-290-9824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number208800000-UROLOGY
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberH4250
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: