Healthcare Provider Details

I. General information

NPI: 1891767943
Provider Name (Legal Business Name): JON C CLYDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 W CATALDO AVE
SPOKANE WA
99201-2217
US

IV. Provider business mailing address

PO BOX 2242
SPOKANE WA
99210-2242
US

V. Phone/Fax

Practice location:
  • Phone: 509-747-6194
  • Fax: 509-838-0824
Mailing address:
  • Phone: 509-747-6194
  • Fax: 509-838-0824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD00027478
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: