Provider Demographics
NPI:1053852608
Name:CLARK, GREGG P
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:P
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 SMYRNA AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19809-1234
Mailing Address - Country:US
Mailing Address - Phone:302-218-1137
Mailing Address - Fax:
Practice Address - Street 1:113 SMYRNA AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19809-1234
Practice Address - Country:US
Practice Address - Phone:302-218-1137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1990063352171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications