Provider Demographics
NPI:1790752954
Name:CLYNE, PATRICK STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:STEPHEN
Last Name:CLYNE
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 1:222 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:CA
Mailing Address - Zip Code:95019-3136
Mailing Address - Country:US
Mailing Address - Phone:831-728-2969
Mailing Address - Fax:
Practice Address - Street 1:222 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019-3136
Practice Address - Country:US
Practice Address - Phone:831-728-2969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79053208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G790530Medicaid
CAG39013Medicare UPIN
CA00G790530Medicaid