Provider Demographics
NPI:1962477695
Name:MECKSTROTH, CLYDE S (DO)
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:S
Last Name:MECKSTROTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5300 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2387
Mailing Address - Country:US
Mailing Address - Phone:561-227-5270
Mailing Address - Fax:561-863-2806
Practice Address - Street 1:15590 MEADOW WOOD DR
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-9009
Practice Address - Country:US
Practice Address - Phone:561-793-0567
Practice Address - Fax:561-863-2806
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5367208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE64657Medicare UPIN
FL80366Medicare ID - Type Unspecified