Provider Demographics
NPI:1245412352
Name:H CLARK DERISO M.D.P.C.
Entity Type:Organization
Organization Name:H CLARK DERISO M.D.P.C.
Other - Org Name:H. CLARK DERISO M.D.P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:DERISO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-692-0755
Mailing Address - Street 1:38 MEDICAL ARTS CTR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4415
Mailing Address - Country:US
Mailing Address - Phone:912-692-0755
Mailing Address - Fax:912-692-0754
Practice Address - Street 1:38 MEDICAL ARTS CENTER
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4155
Practice Address - Country:US
Practice Address - Phone:912-692-0755
Practice Address - Fax:912-692-0754
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:H. CLARK DERISO M.D.P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-30
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013026174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2318Medicare PIN