MEDICARE: CLYDE W WILCOX JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	0101028216	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578549077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLYDE W WILCOX JR. MD

Provider Business Mailing Address
First Line	:	6330 N CENTER DR
Second Line	:	BLDG 13 STE 220
City	:	NORFOLK
State	:	VA
Zip	:	23502-4008
Country	:	US
Telephone Number	:	757-466-0089
Fax Number	:	757-466-8017

Provider Business Practice Location Address
First Line	:	6330 N CENTER DR
Second Line	:	BLDG 13 STE 220
City	:	NORFOLK
State	:	VA
Zip	:	23502-4008
Country	:	US
Telephone Number	:	757-466-0089
Fax Number	:	757-466-8017

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	07/08/2007

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