Provider Demographics
NPI:1649223009
Name:DELLINGER, CLYDE J (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:J
Last Name:DELLINGER
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 547
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-0547
Mailing Address - Country:US
Mailing Address - Phone:843-663-1013
Mailing Address - Fax:843-663-1017
Practice Address - Street 1:4303 LIVE OAK DR
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-9138
Practice Address - Country:US
Practice Address - Phone:843-663-1013
Practice Address - Fax:843-663-1017
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCFQC024Medicaid
421890Medicare ID - Type UnspecifiedUBS MEDICARE
421877Medicare ID - Type UnspecifiedUBS MEDICARE
421889Medicare ID - Type UnspecifiedUBS MEDICARE