Provider Demographics
NPI:1518903608
Name:PRICE, CLYDE KENT (MD)
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:KENT
Last Name:PRICE
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:PO BOX 6479
Mailing Address - Street 2:216 CORDER RD
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088
Mailing Address - Country:US
Mailing Address - Phone:478-923-5872
Mailing Address - Fax:478-922-9020
Practice Address - Street 1:216 CORDER RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088
Practice Address - Country:US
Practice Address - Phone:478-923-5872
Practice Address - Fax:478-922-9020
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7H80207W00000X
NC34436207W00000X
GA067961207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1083QOtherBCBS NC
180031856OtherRAILROAD MEDICARE
NC8969189Medicaid
180031856OtherRAILROAD MEDICARE
E91131Medicare UPIN