Provider Demographics
NPI:1881676526
Name:SMITH, CLYDE R (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CLYDE
Other - Middle Name:RUFUS
Other - Last Name:SMITH
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2280 RIVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-4518
Mailing Address - Country:US
Mailing Address - Phone:901-573-0325
Mailing Address - Fax:
Practice Address - Street 1:6019 WALNUT GROVE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2113
Practice Address - Country:US
Practice Address - Phone:901-226-3610
Practice Address - Fax:901-226-3612
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-14356207Q00000X
TN16756207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3722684Medicaid
TN3722684Medicaid
TNA98299Medicare UPIN