Provider Demographics
NPI:1568480705
Name:SIMMONS, CLYDE WILTON JR (MD)
Entity type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:WILTON
Last Name:SIMMONS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:C
Other - Middle Name:WILTON
Other - Last Name:SIMMONS
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:902 FROSTWOOD DR
Mailing Address - Street 2:SUITE 244
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-2420
Mailing Address - Country:US
Mailing Address - Phone:713-932-6467
Mailing Address - Fax:713-932-0647
Practice Address - Street 1:902 FROSTWOOD DR
Practice Address - Street 2:SUITE 244
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-2420
Practice Address - Country:US
Practice Address - Phone:713-932-6467
Practice Address - Fax:713-932-0647
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD7303174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00L598Medicare ID - Type Unspecified
TXC21829Medicare UPIN