Provider Demographics
NPI:1578566824
Name:CLARK, BENDIK (MD)
Entity Type:Individual
Prefix:DR
First Name:BENDIK
Middle Name:
Last Name:CLARK
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 1:401 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-4877
Mailing Address - Country:US
Mailing Address - Phone:423-929-2584
Mailing Address - Fax:423-722-2060
Practice Address - Street 1:401 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4877
Practice Address - Country:US
Practice Address - Phone:423-929-2584
Practice Address - Fax:423-722-2060
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 36706207Q00000X
VA0101235726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3886276Medicare ID - Type Unspecified
H85944Medicare UPIN
VA006065H81Medicare ID - Type Unspecified