Provider Demographics
NPI:1376721936
Name:CLYDE E HAWORTH JR
Entity Type:Organization
Organization Name:CLYDE E HAWORTH JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HAWORTH
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:401-333-0090
Mailing Address - Street 1:2190 MENDON RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-3805
Mailing Address - Country:US
Mailing Address - Phone:401-333-0090
Mailing Address - Fax:401-333-0490
Practice Address - Street 1:2190 MENDON ROAD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-3805
Practice Address - Country:US
Practice Address - Phone:401-333-0090
Practice Address - Fax:401-333-0490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG495332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0300290001Medicare NSC