Provider Demographics
NPI:1346269339
Name:JOHN M CLARK MD & ASSOCIATES PLLC
Entity Type:Organization
Organization Name:JOHN M CLARK MD & ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MIRRELL
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-201-2545
Mailing Address - Street 1:PO BOX 801
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526
Mailing Address - Country:US
Mailing Address - Phone:304-201-2545
Mailing Address - Fax:304-201-2548
Practice Address - Street 1:3860 TEAYS VALLEY RD
Practice Address - Street 2:SUITE 4
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9772
Practice Address - Country:US
Practice Address - Phone:304-201-2545
Practice Address - Fax:304-201-2548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVI55275Medicare UPIN