Provider Demographics
NPI:1275517831
Name:CLARK, CHAD MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:MICHAEL
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 7055
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89510-7055
Mailing Address - Country:US
Mailing Address - Phone:704-867-8021
Mailing Address - Fax:704-864-4606
Practice Address - Street 1:620 SUMMIT CROSSING PL
Practice Address - Street 2:STE 106
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2176
Practice Address - Country:US
Practice Address - Phone:704-867-8021
Practice Address - Fax:704-864-4606
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004001992085B0100X
NC2004-001992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
1377ROtherBLUE CROSS BLUE SHIELD
SCN0019CMedicaid
7095608OtherAETNA PPO
NC891377RMedicaid
P00183056OtherRAILROAD MEDICARE
804966OtherPARTNERS
D4989OtherMEDCOST
3616084OtherAETNA HMO
560988142OtherUNITED HEALTHCARE
P00183056OtherRAILROAD MEDICARE
7095608OtherAETNA PPO