Provider Demographics
NPI:1558429241
Name:CLARK, ERIC WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:WALTER
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:MTSU STUDENT HEALTH BOX 237
Mailing Address - Street 2:1500 GREENLAND AVENUE
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MTSU STUDENT HEALTH
Practice Address - Street 2:1500 GREENLAND AVE BOX 237
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37132-0001
Practice Address - Country:US
Practice Address - Phone:615-494-7601
Practice Address - Fax:615-898-5004
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000028457207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine