Provider Demographics
NPI:1265409064
Name:CLARK, WINSTON CRAIG (MD)
Entity type:Individual
Prefix:
First Name:WINSTON
Middle Name:CRAIG
Last Name:CLARK
Suffix:
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 1:704 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6107
Mailing Address - Country:US
Mailing Address - Phone:229-584-5760
Mailing Address - Fax:229-584-5945
Practice Address - Street 1:704 S BROAD ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6107
Practice Address - Country:US
Practice Address - Phone:229-584-5760
Practice Address - Fax:229-584-5945
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD14839207T00000X
GA35395207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN162898OtherBCBST
MS00115774Medicaid
TN3029594Medicaid
GA35395OtherLICENSE
A99353Medicare UPIN
MS140000083Medicare PIN