Provider Demographics
NPI:1528011582
Name:CLAYTON, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CLAYTON
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 MEDICAL PARK DR
Practice Address - Street 2:STE 202B
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2981
Practice Address - Country:US
Practice Address - Phone:704-403-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-01521208000000X, 2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC57-6007863092OtherBLUE CHOICE OF SC
SCT63277Medicaid
NC5903238Medicaid
SC4155722OtherCIGNA
SC57-6007863037OtherBCBS OF SC
NC5903238Medicaid
SCT63277Medicaid