Provider Demographics
NPI:1104880434
Name:CLYDE, TOM W (OPTOMETRIST)
Entity type:Individual
Prefix:DR
First Name:TOM
Middle Name:W
Last Name:CLYDE
Suffix:
Gender:M
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5122
Mailing Address - Country:US
Mailing Address - Phone:719-632-1587
Mailing Address - Fax:719-632-1563
Practice Address - Street 1:710 N CIRCLE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5122
Practice Address - Country:US
Practice Address - Phone:719-632-1587
Practice Address - Fax:719-632-1563
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO867152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08008674Medicaid
CO08008674Medicaid
CO840793775OtherTIN#
CO08008674Medicaid