Provider Demographics
NPI:1437232246
Name:HAWORTH, CLYDE E
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:E
Last Name:HAWORTH
Suffix:
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 1:2190 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 RD
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG495152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI419009824Medicare ID - Type Unspecified