Provider Demographics
NPI:1881794519
Name:PITTMAN, CLYDE EDWIN (MD)
Entity type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:EDWIN
Last Name:PITTMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3320 OLD JEFFERSON ROAD
Mailing Address - Street 2:BLDG 100
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30607
Mailing Address - Country:US
Mailing Address - Phone:706-353-3600
Mailing Address - Fax:706-353-3777
Practice Address - Street 1:3320 OLD JEFFERSON ROAD
Practice Address - Street 2:BLDG 100
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607
Practice Address - Country:US
Practice Address - Phone:706-353-3600
Practice Address - Fax:706-353-3777
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA035502208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C86003Medicare UPIN
GA24BCBJPMedicare ID - Type Unspecified