Provider Demographics
NPI:1386673838
Name:WITHERSPOON, CLARK DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:DOUGLAS
Last Name:WITHERSPOON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1720 UNIVERSITY BLVD
Mailing Address - Street 2:SUITE 601
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35294-0009
Mailing Address - Country:US
Mailing Address - Phone:205-325-8620
Mailing Address - Fax:205-558-2553
Practice Address - Street 1:1720 UNIVERSITY BLVD
Practice Address - Street 2:SUITE 601
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35294-0009
Practice Address - Country:US
Practice Address - Phone:205-325-8620
Practice Address - Fax:205-558-2553
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL8455207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC75285Medicare UPIN
AL051500164Medicare ID - Type Unspecified