Provider Demographics
NPI:1457562357
Name:DOROMAL, CLYDE GLENN GORDON (RPT, PTRP)
Entity Type:Individual
Prefix:MR
First Name:CLYDE GLENN
Middle Name:GORDON
Last Name:DOROMAL
Suffix:
Gender:M
Credentials:RPT, PTRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MAPLE VALLEY DR
Mailing Address - Street 2:PANG APARTMENT 17
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1979
Mailing Address - Country:US
Mailing Address - Phone:870-329-1625
Mailing Address - Fax:
Practice Address - Street 1:400 MAPLE VALLEY DR
Practice Address - Street 2:PANG APARTMENT 17
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1973
Practice Address - Country:US
Practice Address - Phone:870-329-1625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006010374225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist