Provider Demographics
NPI:1609817832
Name:CLARK, WILLIAM S (ME)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:S
Last Name:CLARK
Suffix:
Gender:M
Credentials:ME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2719 NEUSE BLVD
Mailing Address - Street 2:B & C
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-2840
Mailing Address - Country:US
Mailing Address - Phone:252-633-6117
Mailing Address - Fax:252-633-2644
Practice Address - Street 1:2719 NEUSE BLVD
Practice Address - Street 2:B & C
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-2840
Practice Address - Country:US
Practice Address - Phone:252-633-6117
Practice Address - Fax:252-633-2644
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33966207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8922615Medicaid
E94016Medicare UPIN
NC2162638Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER