Provider Demographics
NPI:1568496958
Name:FORD, CLYDE DEJONG (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:DEJONG
Last Name:FORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CLYDE
Other - Middle Name:D
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-535-8163
Mailing Address - Fax:801-355-4011
Practice Address - Street 1:8 TH AVENUE AND C ST
Practice Address - Street 2:BONE MARROW TRANSPLANT
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84143-0001
Practice Address - Country:US
Practice Address - Phone:801-408-3729
Practice Address - Fax:801-408-8453
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT158790-1205207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT91515OtherPEHP
UT6891OtherDMBA
UT296662OtherALTIUS
UT107005107110OtherSELECT HEALTH
UT91515OtherPEHP
UT107005107110OtherSELECT HEALTH