Provider Demographics
NPI:1366509259
Name:WILSON, CLYDE H (MD)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:H
Last Name:WILSON
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 1:3223 1ST AVENUE SOUTH
Mailing Address - Street 2:SUITE C
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98134
Mailing Address - Country:US
Mailing Address - Phone:206-624-3651
Mailing Address - Fax:206-624-2391
Practice Address - Street 1:3223 1ST AVENUE SOUTH
Practice Address - Street 2:SUITE C
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98134
Practice Address - Country:US
Practice Address - Phone:206-624-3651
Practice Address - Fax:206-624-2391
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0000314712083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A63970Medicare UPIN
000173933Medicare ID - Type Unspecified