Provider Demographics
NPI:1225019862
Name:CLARK, TIMOTHY J (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30750
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27833-0750
Mailing Address - Country:US
Mailing Address - Phone:252-752-5000
Mailing Address - Fax:252-931-7694
Practice Address - Street 1:2101 W ARLINGTON BLVD STE 210
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5758
Practice Address - Country:US
Practice Address - Phone:252-752-5000
Practice Address - Fax:252-931-7694
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00287422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8922739Medicaid
NC22739OtherBLUE CROSS BLUE SHIELD NORTH CAROLING
NC2144065CMedicare PIN
NCE29356Medicare UPIN
NC560994806BOtherCIGNA
NCE29356Medicare UPIN