Provider Demographics
NPI:1386640241
Name:CLARK, GERALD H (MD)
Entity Type:Individual
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First Name:GERALD
Middle Name:H
Last Name:CLARK
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1285 HEMBREE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5715
Mailing Address - Country:US
Mailing Address - Phone:770-442-1050
Mailing Address - Fax:770-442-9618
Practice Address - Street 1:1285 HEMBREE RD
Practice Address - Street 2:STE 100
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5715
Practice Address - Country:US
Practice Address - Phone:770-442-1050
Practice Address - Fax:770-442-9618
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-09
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Provider Licenses
StateLicense IDTaxonomies
GA0260832080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D45066Medicare UPIN