Provider Demographics
NPI:1538277421
Name:FARRIS, CLYDE ALAN (MD)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:ALAN
Last Name:FARRIS
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 1:19250 SW 65TH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062
Mailing Address - Country:US
Mailing Address - Phone:503-692-6990
Mailing Address - Fax:503-691-6387
Practice Address - Street 1:19250 SW 65TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062
Practice Address - Country:US
Practice Address - Phone:503-692-6990
Practice Address - Fax:503-691-6387
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11437207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR066514Medicaid
OR066514Medicaid
OR0395130001Medicare NSC
A43766Medicare UPIN