Provider Demographics
NPI:1629046289
Name:CLARK, GREG D (DPM)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:2130 HIGHWAY 35
Mailing Address - Street 2:BLDG C STE 312
Mailing Address - City:SEA GIRT
Mailing Address - State:NJ
Mailing Address - Zip Code:08750-1010
Mailing Address - Country:US
Mailing Address - Phone:732-974-8200
Mailing Address - Fax:732-974-0190
Practice Address - Street 1:2130 HIGHWAY 35
Practice Address - Street 2:BLDG C STE 312
Practice Address - City:SEA GIRT
Practice Address - State:NJ
Practice Address - Zip Code:08750-1010
Practice Address - Country:US
Practice Address - Phone:732-974-8200
Practice Address - Fax:732-974-0190
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MD00282000213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD08685300OtherCDS
NJ25MD00282000OtherLICENSE
NJ25MD00282000OtherLICENSE
NJBC9275199OtherDEA
NJ25MD00282000OtherLICENSE