Provider Demographics
NPI:1609982081
Name:CLARK, MARC L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:L
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:870 STATE FARM RD
Mailing Address - Street 2:STE 102
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-4861
Mailing Address - Country:US
Mailing Address - Phone:828-264-0029
Mailing Address - Fax:828-265-3305
Practice Address - Street 1:870 STATE FARM RD
Practice Address - Street 2:STE 102
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4861
Practice Address - Country:US
Practice Address - Phone:828-264-0029
Practice Address - Fax:828-265-3305
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN16869207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
62-1482379OtherTAX ID
3702765OtherMEDICARE GROUP NUMBER
62-1482379OtherTAX ID
3702765OtherMEDICARE GROUP NUMBER