Provider Demographics
NPI:1285181222
Name:ANDERSON, CLYDE III
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:ANDERSON
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 CAMPUS VILLAGE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-8805
Mailing Address - Country:US
Mailing Address - Phone:810-965-4642
Mailing Address - Fax:
Practice Address - Street 1:2103 CAMPUS VILLAGE AVE APT 3
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-8805
Practice Address - Country:US
Practice Address - Phone:810-965-4642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer