Provider Demographics
NPI:1538117528
Name:CLARK, CURTIS E JR (DO)
Entity Type:Individual
Prefix:
First Name:CURTIS
Middle Name:E
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7000
Mailing Address - Fax:615-920-8775
Practice Address - Street 1:610 19TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1528
Practice Address - Country:US
Practice Address - Phone:706-322-7884
Practice Address - Fax:706-660-2142
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047068207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000893538LMedicaid
GA202I930734Medicare PIN
GA000893538LMedicaid
GAH10877Medicare UPIN
GA000893538KMedicaid