Provider Demographics
NPI:1043285794
Name:NOLAN, CLYDE JR (MD)
Entity type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:
Last Name:NOLAN
Suffix:JR
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 1:1317 N ELM ST
Mailing Address - Street 2:PARKVIEW PLAZA, STE 9
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1033
Mailing Address - Country:US
Mailing Address - Phone:336-379-1193
Mailing Address - Fax:336-379-1195
Practice Address - Street 1:1317 N ELM ST
Practice Address - Street 2:PARKVIEW PLAZA, STE 9
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1033
Practice Address - Country:US
Practice Address - Phone:336-379-1193
Practice Address - Fax:336-379-1195
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23067207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8962953Medicaid
NC203020Medicare ID - Type Unspecified
NC8962953Medicaid