Provider Demographics
NPI:1225010754
Name:CLARK, DAVID M (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 925
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-0925
Mailing Address - Country:US
Mailing Address - Phone:706-724-8611
Mailing Address - Fax:706-724-6202
Practice Address - Street 1:818 SAINT SEBASTIAN WAY
Practice Address - Street 2:SUITE 311
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2651
Practice Address - Country:US
Practice Address - Phone:706-724-3473
Practice Address - Fax:706-724-3493
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA043579207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA597816OtherBCBS
SCG43579Medicaid
GA000749801AMedicaid
GAF30495Medicare UPIN