Provider Demographics
NPI:1831402841
Name:CLYDE, JOHN KITTRELL (DPM)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KITTRELL
Last Name:CLYDE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 N MULLAN RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-2408
Mailing Address - Country:US
Mailing Address - Phone:509-924-2600
Mailing Address - Fax:509-926-9865
Practice Address - Street 1:526 N MULLAN RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-2408
Practice Address - Country:US
Practice Address - Phone:099-242-6005
Practice Address - Fax:509-926-9865
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO60253252213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2020121Medicaid
WAG8909958Medicare PIN