Provider Demographics
NPI:1225129117
Name:SHREVE, CLYDEEVE A (DPM)
Entity Type:Individual
Prefix:
First Name:CLYDEEVE
Middle Name:A
Last Name:SHREVE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5640 WASATCH DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4902
Mailing Address - Country:US
Mailing Address - Phone:801-392-7507
Mailing Address - Fax:801-393-0725
Practice Address - Street 1:5640 WASATCH DR
Practice Address - Street 2:SUITE F
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4902
Practice Address - Country:US
Practice Address - Phone:801-392-7507
Practice Address - Fax:801-393-0725
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101694-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5177150001OtherDEMERK PROVIDER ID
UTP00100541OtherRR MEDICARE PROVIDER ID
UTP00100541OtherRR MEDICARE PROVIDER ID