Provider Demographics
NPI:1639431307
Name:CLARK, BRADLEY WALTON (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:WALTON
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:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-277-2000
Mailing Address - Fax:336-277-2050
Practice Address - Street 1:7114 VILLAGE MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8004
Practice Address - Country:US
Practice Address - Phone:336-893-2440
Practice Address - Fax:336-893-2470
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00428207R00000X, 207RC0000X, 207UN0901X
SCLL34733207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease