Provider Demographics
NPI:1649354432
Name:CLAYVILLE, TERRY LEE (OD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:LEE
Last Name:CLAYVILLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7291 BOULDER AVE
Mailing Address - Street 2:STE 2D
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-3389
Mailing Address - Country:US
Mailing Address - Phone:909-425-1212
Mailing Address - Fax:909-425-2485
Practice Address - Street 1:7291 BOULDER AVE
Practice Address - Street 2:STE 2D
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-3389
Practice Address - Country:US
Practice Address - Phone:909-425-1212
Practice Address - Fax:909-425-2485
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA08157152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0081570Medicaid
CASD0081570Medicare ID - Type Unspecified
CASD0081570Medicaid