Provider Demographics
NPI:1174569123
Name:MORELAND, CLYDE HAMILTON (MD)
Entity type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:HAMILTON
Last Name:MORELAND
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 1:3251 3RD AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8506
Mailing Address - Country:US
Mailing Address - Phone:727-321-3854
Mailing Address - Fax:727-327-7670
Practice Address - Street 1:3251 3RD AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8506
Practice Address - Country:US
Practice Address - Phone:727-321-3854
Practice Address - Fax:727-327-7670
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63178207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL18759OtherBCBS
FL930100653OtherRR MEDICARE
FL260480900Medicaid
FL260480900Medicaid
FL930100653OtherRR MEDICARE