Provider Demographics
NPI:1356315428
Name:CLARK, DEANDRA L (MD)
Entity Type:Individual
Prefix:
First Name:DEANDRA
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N FANT ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5702
Mailing Address - Country:US
Mailing Address - Phone:864-225-7798
Mailing Address - Fax:864-512-3952
Practice Address - Street 1:500 N FANT ST
Practice Address - Street 2:SUITE C
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5702
Practice Address - Country:US
Practice Address - Phone:864-225-7798
Practice Address - Fax:864-512-3952
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76610208000000X
SCTL32184208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258609600Medicaid
H15419Medicare UPIN
FL258609600Medicaid