Provider Demographics
NPI:1003866443
Name:CLARK, JOHN B JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1900 RANDOLPH RD
Mailing Address - Street 2:STE 900
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1106
Mailing Address - Country:US
Mailing Address - Phone:704-377-2424
Mailing Address - Fax:704-377-2687
Practice Address - Street 1:1900 RANDOLPH RD
Practice Address - Street 2:STE 900
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1106
Practice Address - Country:US
Practice Address - Phone:704-377-2424
Practice Address - Fax:704-377-2687
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-10-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC23260207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN23260Medicaid
NC22664OtherBCBSNC
NC930067545OtherRR MEDICARE
NC89-22664Medicaid
NC205438GMedicare PIN
NC930067545OtherRR MEDICARE