Provider Demographics
NPI:1780644252
Name:COLVARD, M CLARK JR (MD)
Entity Type:Individual
Prefix:
First Name:M
Middle Name:CLARK
Last Name:COLVARD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MERRIMAN
Other - Middle Name:C
Other - Last Name:COLVARD
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1604 GUNBARREL RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3125
Mailing Address - Country:US
Mailing Address - Phone:423-648-2395
Mailing Address - Fax:423-648-7542
Practice Address - Street 1:4700 BATTLEFIELD PKWY
Practice Address - Street 2:STE 100
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736-5166
Practice Address - Country:US
Practice Address - Phone:706-806-0170
Practice Address - Fax:706-806-0200
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028388207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000318216FMedicaid
54121OtherBX TN
GA000318216DMedicaid
GA000318216CMedicaid
060004408OtherRR MEDICARE