Provider Demographics
NPI:1235193582
Name:SIMMONS, CLYDE G (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:G
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7627
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-7627
Mailing Address - Country:US
Mailing Address - Phone:229-396-5830
Mailing Address - Fax:229-391-3686
Practice Address - Street 1:5488 N ALABAMA AVE
Practice Address - Street 2:
Practice Address - City:OMEGA
Practice Address - State:GA
Practice Address - Zip Code:31775-3054
Practice Address - Country:US
Practice Address - Phone:229-528-4546
Practice Address - Fax:229-528-4841
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA17301174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000191155EMedicaid
GA000191155AMedicaid
GA000191155FMedicaid