Provider Demographics
NPI:1306849575
Name:CLARK, SHAWN B (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:B
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6701 AIRPORT BLVD STE D146
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-3784
Mailing Address - Country:US
Mailing Address - Phone:251-287-2176
Mailing Address - Fax:251-287-2279
Practice Address - Street 1:6701 AIRPORT BLVD STE D146
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3784
Practice Address - Country:US
Practice Address - Phone:251-287-2176
Practice Address - Fax:251-287-2279
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL23993207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL120636Medicaid
H40831Medicare UPIN
AL102L149475Medicare PIN