Provider Demographics
NPI:1255565149
Name:NOBLES, CLYDE JR (IDMT)
Entity type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:
Last Name:NOBLES
Suffix:JR
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 MDG
Mailing Address - Street 2:
Mailing Address - City:SCOTT AFB
Mailing Address - State:IL
Mailing Address - Zip Code:62225
Mailing Address - Country:US
Mailing Address - Phone:618-256-7551
Mailing Address - Fax:
Practice Address - Street 1:375 MDG
Practice Address - Street 2:
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225
Practice Address - Country:US
Practice Address - Phone:618-256-7551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians