Provider Demographics
NPI:1700896552
Name:CLYDE, BRENT LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:LEE
Last Name:CLYDE
Suffix:
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 1:7261 MERCY RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2311
Mailing Address - Country:US
Mailing Address - Phone:402-398-6248
Mailing Address - Fax:402-829-8513
Practice Address - Street 1:7710 MERCY RD STE 2000
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2323
Practice Address - Country:US
Practice Address - Phone:402-717-0880
Practice Address - Fax:402-717-0880
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4821912-1205174400000X
MIEMC0002923207T00000X
NE31812207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1174436 00Medicaid
WY1174436 00Medicaid
WYG52536Medicare UPIN
UT140007529Medicare ID - Type UnspecifiedRR MEDICARE
UT000012390Medicare ID - Type Unspecified
WYW9203Medicare ID - Type Unspecified
WY1174436 00Medicaid