Provider Demographics
NPI:1104987007
Name:FENTON, CLYDE M (OD)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:M
Last Name:FENTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 ROBINSON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3650
Mailing Address - Country:US
Mailing Address - Phone:740-353-5351
Mailing Address - Fax:740-353-8647
Practice Address - Street 1:2002 ROBINSON AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3650
Practice Address - Country:US
Practice Address - Phone:740-353-5351
Practice Address - Fax:740-353-8647
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3023152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0344541Medicaid
OH0544680001Medicare NSC
OHT46798Medicare UPIN
OH0424182Medicare ID - Type Unspecified