Provider Demographics
NPI:1053308288
Name:CLARK, JOSEPH M (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 24848
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-4848
Mailing Address - Country:US
Mailing Address - Phone:336-538-1966
Mailing Address - Fax:336-538-1729
Practice Address - Street 1:1248 HUFFMAN MILL RD
Practice Address - Street 2:STE 201
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8700
Practice Address - Country:US
Practice Address - Phone:336-538-1966
Practice Address - Fax:336-538-1729
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC9700217207YX0007X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2003339Medicare ID - Type Unspecified
800558Medicare ID - Type UnspecifiedMEDICARE PARTNERS
H28186Medicare UPIN
243465OtherMAMSI
1000157OtherUNITED HEALTHCARE
040017425Medicare ID - Type UnspecifiedRAILROAD MEDICARE
NC2003339Medicare ID - Type Unspecified
NC89131W8Medicaid
NC131W8OtherBCBS
7089242OtherAETNA