Provider Demographics
NPI:1356313969
Name:CLARK, DENNIS DEWAYNE (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:DEWAYNE
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 5430
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36205-0430
Mailing Address - Country:US
Mailing Address - Phone:256-237-1624
Mailing Address - Fax:256-238-0555
Practice Address - Street 1:111 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36205-4101
Practice Address - Country:US
Practice Address - Phone:256-237-1624
Practice Address - Fax:256-238-0555
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23397174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL020048856OtherUNITED HEALTHCARE
AL51097064OtherBLUE CROSS BLUE SHIELD
AL000097064Medicaid
AL020048856OtherUNITED HEALTHCARE