Provider Demographics
NPI:1982673562
Name:HURST, CLYDE O JR (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:O
Last Name:HURST
Suffix:JR
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 1:5001 HIGHWAY 190
Mailing Address - Street 2:SUITE D-5
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-4930
Mailing Address - Country:US
Mailing Address - Phone:985-892-9505
Mailing Address - Fax:985-892-9505
Practice Address - Street 1:5001 HIGHWAY 190
Practice Address - Street 2:SUITE D-5
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4956
Practice Address - Country:US
Practice Address - Phone:985-892-9505
Practice Address - Fax:985-892-9505
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0179372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA55173Medicare ID - Type Unspecified
LAB65648Medicare UPIN