Provider Demographics
NPI:1235268186
Name:IMHOFF, JR., CLYDE L (DO)
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:L
Last Name:IMHOFF, JR.
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-2957
Mailing Address - Country:US
Mailing Address - Phone:928-782-4325
Mailing Address - Fax:928-782-4326
Practice Address - Street 1:411 W 8TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-2957
Practice Address - Country:US
Practice Address - Phone:928-782-4325
Practice Address - Fax:928-782-4326
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1062204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD47221Medicare UPIN