Healthcare Provider Details

I. General information

NPI: 1972866283
Provider Name (Legal Business Name): JON-MICHAEL GLEN CLINE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 10/22/2022
Certification Date: 10/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3414 GOLDEN RD
TYLER TX
75701-8336
US

IV. Provider business mailing address

3414 GOLDEN RD
TYLER TX
75701-8336
US

V. Phone/Fax

Practice location:
  • Phone: 903-939-7500
  • Fax:
Mailing address:
  • Phone: 903-939-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberBP10044610
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberP8872
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberP8872
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: