Provider Demographics
NPI:1083789002
Name:TERRY A. CLYBURN, M. D., P.A.
Entity Type:Organization
Organization Name:TERRY A. CLYBURN, M. D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:CLYBURN
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:713-357-4752
Mailing Address - Street 1:PO BOX 4356
Mailing Address - Street 2:DEPT. 967
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4356
Mailing Address - Country:US
Mailing Address - Phone:713-357-4752
Mailing Address - Fax:
Practice Address - Street 1:5420 WEST LOOP S
Practice Address - Street 2:SUITE 2400
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-2107
Practice Address - Country:US
Practice Address - Phone:713-357-4752
Practice Address - Fax:832-213-0308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3846174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0085PAOtherBCBS
TX00DF11Medicare PIN