Healthcare Provider Details

I. General information

NPI: 1730106592
Provider Name (Legal Business Name): CLYDE G. MOXLEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 AMALIA DR SUITE B-1
BUCKHANNON WV
26201-2271
US

IV. Provider business mailing address

10 AMALIA DR SUITE B-1
BUCKHANNON WV
26201-2271
US

V. Phone/Fax

Practice location:
  • Phone: 304-473-2200
  • Fax: 304-473-2057
Mailing address:
  • Phone: 304-473-2200
  • Fax: 304-473-2057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1846
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: