Provider Demographics
NPI:1447237714
Name:HEAD, CLARENCE ALVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:ALVIN
Last Name:HEAD
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 28068
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37424-8068
Mailing Address - Country:US
Mailing Address - Phone:423-424-3871
Mailing Address - Fax:423-899-0928
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:ROOM 2144
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:423-424-3871
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034154207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGPA854Medicaid
SCGPA854Medicaid
GAF67600Medicare UPIN