Provider Demographics
NPI:1346324977
Name:MARTIN, CLYDE SYDNEY (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:SYDNEY
Last Name:MARTIN
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 1:119 EPPERSON ST
Mailing Address - Street 2:PO BOX 726
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37303-3478
Mailing Address - Country:US
Mailing Address - Phone:423-745-7500
Mailing Address - Fax:423-745-7501
Practice Address - Street 1:119 EPPERSON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-3478
Practice Address - Country:US
Practice Address - Phone:423-745-7500
Practice Address - Fax:423-745-7501
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000012786208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN37363OtherBLUE CROSS BLUE SHIELD
TNA97294Medicare UPIN
TN3008399Medicare ID - Type Unspecified