Provider Demographics
NPI:1093744427
Name:CLARK, BRIAN THOMAS (IDC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:THOMAS
Last Name:CLARK
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3972 SHADY OAKS DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-1628
Mailing Address - Country:US
Mailing Address - Phone:757-630-7081
Mailing Address - Fax:
Practice Address - Street 1:3972 SHADY OAKS DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-1628
Practice Address - Country:US
Practice Address - Phone:757-630-7081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman