Provider Demographics
NPI:1891767943
Name:CLYDE, JON C (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:C
Last Name:CLYDE
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:PO BOX 2242
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99210-2242
Mailing Address - Country:US
Mailing Address - Phone:509-747-6194
Mailing Address - Fax:509-838-0824
Practice Address - Street 1:217 W CATALDO AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2217
Practice Address - Country:US
Practice Address - Phone:509-747-6194
Practice Address - Fax:509-838-0824
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027478208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA305785OtherLABOR& INDUSTRIES
WAP01152325OtherRAILROAD MEDICARE
WA1021532Medicaid
WA305785OtherLABOR& INDUSTRIES
WAG8913948Medicare PIN