Provider Demographics
NPI:1245890672
Name:CLARK, JOHN DOUGLAS JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DOUGLAS
Last Name:CLARK
Suffix:JR
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 1:54 MEADOWBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-8543
Mailing Address - Country:US
Mailing Address - Phone:828-553-7860
Mailing Address - Fax:
Practice Address - Street 1:54 MEADOWBROOK CIR
Practice Address - Street 2:
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-8543
Practice Address - Country:US
Practice Address - Phone:828-553-7860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC94-01153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine