Provider Demographics
NPI:1407855802
Name:CLY, GEOFFREY C (MD)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:C
Last Name:CLY
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 1:3926 NEW VISION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1712
Mailing Address - Country:US
Mailing Address - Phone:260-266-8210
Mailing Address - Fax:260-458-5636
Practice Address - Street 1:11123 PARKVIEW PLAZA DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1707
Practice Address - Country:US
Practice Address - Phone:260-422-7455
Practice Address - Fax:260-424-9356
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057955A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200446790Medicaid
IN000000595614OtherANTHEM
IN000000512001OtherANTHEM PROVIDER ID# - WHC
IN200446790AMedicaid
INH42291Medicare UPIN
IN259190BMedicare PIN
IN070860HHMedicare PIN
IN200446790Medicaid