Provider Demographics
NPI:1063851277
Name:CLARK, CARLOS STANFORD II (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:STANFORD
Last Name:CLARK
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:201 DOCTORS DRIVE
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301
Mailing Address - Country:US
Mailing Address - Phone:334-794-6612
Mailing Address - Fax:334-794-6614
Practice Address - Street 1:201 DOCTORS DRIVE
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301
Practice Address - Country:US
Practice Address - Phone:334-794-6612
Practice Address - Fax:334-794-6614
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2013-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ALMD.32611207Q00000X
FLME116951207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine