Provider Demographics
NPI:1669628442
Name:CLYDE E. CROOM, OD, PA
Entity Type:Organization
Organization Name:CLYDE E. CROOM, OD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:E
Authorized Official - Last Name:CROOM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:919-834-6206
Mailing Address - Street 1:11 ENTERPRISE ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7323
Mailing Address - Country:US
Mailing Address - Phone:919-834-6206
Mailing Address - Fax:
Practice Address - Street 1:11 ENTERPRISE ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7323
Practice Address - Country:US
Practice Address - Phone:919-834-6206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC791332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0705340001Medicare NSC