Provider Demographics
NPI:1225131311
Name:CLARK, SHERRI BENNETT (MD)
Entity Type:Individual
Prefix:DR
First Name:SHERRI
Middle Name:BENNETT
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4745 CHACE CIR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-3711
Mailing Address - Country:US
Mailing Address - Phone:205-733-7110
Mailing Address - Fax:205-733-7859
Practice Address - Street 1:4745 CHACE CIR
Practice Address - Street 2:SUITE 101
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-3711
Practice Address - Country:US
Practice Address - Phone:205-733-7110
Practice Address - Fax:205-733-7859
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL129690Medicaid
ALSC00078589Medicaid
AL129690Medicaid
ALSC00078589Medicaid
AL102I082801Medicare PIN