Provider Demographics
NPI:1306838453
Name:CLARK, JAMES PAUL II (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:PAUL
Last Name:CLARK
Suffix:II
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 1:3411A NOYES AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304
Mailing Address - Country:US
Mailing Address - Phone:304-344-2459
Mailing Address - Fax:304-345-1336
Practice Address - Street 1:3411A NOYES AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-344-2459
Practice Address - Fax:304-345-1336
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17504207KA0200X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5720204OtherAETNA
WV001722434OtherBLUE CROSS BS
WV0079196000Medicaid
F65787Medicare UPIN