Provider Demographics
NPI:1093700320
Name:CLARK, GLENN L (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:L
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 1128
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-1128
Mailing Address - Country:US
Mailing Address - Phone:337-824-4403
Mailing Address - Fax:337-824-9731
Practice Address - Street 1:4250 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-1917
Practice Address - Country:US
Practice Address - Phone:850-718-2597
Practice Address - Fax:850-718-2551
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME420962085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32068Medicare ID - Type Unspecified
C76060Medicare UPIN