Provider Demographics
NPI:1700864238
Name:CLARK, WALTER D (DPM)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 ST. VINCENT'S DRIVE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-2704
Mailing Address - Country:US
Mailing Address - Phone:205-324-8511
Mailing Address - Fax:205-314-8551
Practice Address - Street 1:805 ST. VINCENT'S DRIVE
Practice Address - Street 2:SUITE 420
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-2704
Practice Address - Country:US
Practice Address - Phone:205-324-8511
Practice Address - Fax:205-314-8551
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0048213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALCL000070338Medicaid
AL051070338OtherBLUE CROSS
AL0538190002Medicare NSC
ALCL000070338Medicaid
AL000070338Medicare PIN