Provider Demographics
NPI:1598739682
Name:CLARK, LOUIS PHILLIP JR (MD)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:PHILLIP
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4140 FERNCREEK DR
Mailing Address - Street 2:SUITE 801
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2563
Mailing Address - Country:US
Mailing Address - Phone:910-484-2171
Mailing Address - Fax:910-484-4568
Practice Address - Street 1:4140 FERNCREEK DR
Practice Address - Street 2:SUITE 801
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2563
Practice Address - Country:US
Practice Address - Phone:910-484-2171
Practice Address - Fax:910-484-4568
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC27779207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC22718OtherBCBS INDIVIDUAL ID NUMBER
NC8922718Medicaid
NC8922718Medicaid
NCD33100Medicare UPIN