Healthcare Provider Details

I. General information

NPI: 1699764340
Provider Name (Legal Business Name): RAYMOND JOSEPH CLYDESDALE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 06/12/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 MEDICAL GROUP 77 NEALY AVENUE
HAMPTON VA
23665-2040
US

IV. Provider business mailing address

633 MEDICAL GROUP 77 NEALY AVENUE
LANGLEY AFB VA
23665
US

V. Phone/Fax

Practice location:
  • Phone: 757-225-7630
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberOS12364
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS12364
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberOS12364
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: