Provider Demographics
NPI:1487641304
Name:CALHOUN, CLYDE R JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:R
Last Name:CALHOUN
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 1:5780 PEACHTREE DUNWOODY ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1513
Mailing Address - Country:US
Mailing Address - Phone:404-303-1224
Mailing Address - Fax:404-303-1325
Practice Address - Street 1:5780 PEACHTREE DUNWOODY ROAD
Practice Address - Street 2:SUITE 320
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1513
Practice Address - Country:US
Practice Address - Phone:404-256-2943
Practice Address - Fax:404-256-6027
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018367174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000117048JMedicaid
GA000117048EMedicaid
GA000117048DMedicaid
GA000117048DMedicaid