Provider Demographics
NPI:1700853629
Name:CLYDE, HARRIE ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:HARRIE
Middle Name:ROBERT
Last Name:CLYDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:H
Other - Middle Name:ROBERT
Other - Last Name:CLYDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1600 W CHANDLER BLVD
Mailing Address - Street 2:#160C
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6100
Mailing Address - Country:US
Mailing Address - Phone:480-899-1696
Mailing Address - Fax:480-963-6227
Practice Address - Street 1:1600 W CHANDLER BLVD
Practice Address - Street 2:#160C
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6100
Practice Address - Country:US
Practice Address - Phone:480-899-1696
Practice Address - Fax:480-963-6227
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11161208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ23989901Medicaid
C99283Medicare UPIN
AZZMD11161Medicare ID - Type Unspecified