Provider Demographics
NPI:1578549077
Name:WILCOX, CLYDE W JR (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:W
Last Name:WILCOX
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 1:6330 N CENTER DR
Mailing Address - Street 2:BLDG 13 STE 220
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4008
Mailing Address - Country:US
Mailing Address - Phone:757-466-0089
Mailing Address - Fax:757-466-8017
Practice Address - Street 1:6330 N CENTER DR
Practice Address - Street 2:BLDG 13 STE 220
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4008
Practice Address - Country:US
Practice Address - Phone:757-466-0089
Practice Address - Fax:757-466-8017
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010282162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7229321Medicaid
VA7229321Medicaid