Provider Demographics
NPI:1851667380
Name:CLARK, TAVIA DENISE (MD)
Entity Type:Individual
Prefix:DR
First Name:TAVIA
Middle Name:DENISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:2525 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2140
Practice Address - Country:US
Practice Address - Phone:704-834-2000
Practice Address - Fax:704-834-2500
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA264842208000000X
ORMD174941208000000X
WAMD60584128208000000X
PAMD455243208000000X
NC2015-02140208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics