Provider Demographics
NPI:1174983670
Name:HOMER CLARK HYDE MD, PC
Entity type:Organization
Organization Name:HOMER CLARK HYDE MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOMER
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:HYDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-751-0051
Mailing Address - Street 1:12901 RIVER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-5163
Mailing Address - Country:US
Mailing Address - Phone:405-751-0051
Mailing Address - Fax:405-751-6902
Practice Address - Street 1:4140 W MEMORIAL RD
Practice Address - Street 2:SUITE 422
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8366
Practice Address - Country:US
Practice Address - Phone:405-751-0051
Practice Address - Fax:405-751-6902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200631400AMedicaid
OK480556Medicare PIN