Provider Demographics
NPI:1669458113
Name:PENCE, CLYDE MORRIS (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:MORRIS
Last Name:PENCE
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 1:14055 VALLEY VIEW LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244
Mailing Address - Country:US
Mailing Address - Phone:877-868-5351
Mailing Address - Fax:
Practice Address - Street 1:512 CROFTON PARK LN
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37069-6516
Practice Address - Country:US
Practice Address - Phone:850-218-3404
Practice Address - Fax:850-474-8096
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36307207RN0300X
TNMD0000057227207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009935449Medicaid
FL17471OtherBLUE CROSS BLUE SHIELD
5904025OtherAETNA
FL065065000Medicaid
AL009935449Medicaid
FL17471OtherBLUE CROSS BLUE SHIELD
D53294Medicare UPIN