Provider Demographics
NPI:1013987759
Name:CLARK, GARY WAYNE (DO)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:WAYNE
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:82 5TH ST NE
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:44615-1214
Mailing Address - Country:US
Mailing Address - Phone:330-627-3494
Mailing Address - Fax:330-627-3494
Practice Address - Street 1:125 CANTON RD NW
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:44615-1009
Practice Address - Country:US
Practice Address - Phone:330-627-7641
Practice Address - Fax:330-627-5796
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO785207Q00000X
OH011418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine