Provider Demographics
NPI:1417928284
Name:MOORE, CLARK D III (MD)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:D
Last Name:MOORE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:191 CENTRE SOUTH BLVD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-6313
Mailing Address - Country:US
Mailing Address - Phone:803-335-2281
Mailing Address - Fax:803-937-1706
Practice Address - Street 1:191 CENTRE SOUTH BLVD
Practice Address - Street 2:SUITE 10
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-6313
Practice Address - Country:US
Practice Address - Phone:803-335-2281
Practice Address - Fax:803-937-1706
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2017-01-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC10145207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC101455Medicaid
SC57-0724225OtherTAX ID
SC101455Medicaid
SC57-0724225OtherTAX ID
SCD907212243Medicare UPIN