Provider Demographics
NPI:1053474080
Name:CLARK, EDWARD JOSEPH III (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOSEPH
Last Name:CLARK
Suffix:III
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:PO BOX 12156
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23612-2156
Mailing Address - Country:US
Mailing Address - Phone:757-867-6101
Mailing Address - Fax:757-867-6588
Practice Address - Street 1:1705 S. TARBORO ST
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893
Practice Address - Country:US
Practice Address - Phone:252-399-8928
Practice Address - Fax:252-399-7313
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2001010282085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00129619OtherRAILROAD MEDICARE
NC891297GMedicaid
NC1297GOtherBCBS
NCP00129619OtherRAILROAD MEDICARE
NC2295839AMedicare ID - Type Unspecified