Provider Demographics
NPI:1245230705
Name:HYDE, HOMER CLARK JR (MD)
Entity Type:Individual
Prefix:
First Name:HOMER
Middle Name:CLARK
Last Name:HYDE
Suffix:JR
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 1:4140 W MEMORIAL RD
Mailing Address - Street 2:SUITE 422
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8366
Mailing Address - Country:US
Mailing Address - Phone:405-751-0051
Mailing Address - Fax:405-751-0051
Practice Address - Street 1:4140 W MEMORIAL RD
Practice Address - Street 2:SUITE 422
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8366
Practice Address - Country:US
Practice Address - Phone:405-751-0051
Practice Address - Fax:405-751-0051
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8687208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK202130641012OtherBC/BS
OK100253200AMedicaid
OK202130641012OtherBC/BS
OK246705702Medicare PIN
E11365Medicare UPIN
OK100253200AMedicaid