Provider Demographics
NPI:1396737680
Name:CLARK, TOREY B (MD)
Entity type:Individual
Prefix:DR
First Name:TOREY
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W LANIER AVE
Mailing Address - Street 2:SUITE 406
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7636
Mailing Address - Country:US
Mailing Address - Phone:678-817-5355
Mailing Address - Fax:678-817-5339
Practice Address - Street 1:500 W LANIER AVE
Practice Address - Street 2:SUITE 406
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7636
Practice Address - Country:US
Practice Address - Phone:678-817-5355
Practice Address - Fax:678-817-5339
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036943174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
83BBBSBMedicare PIN
GAE53663Medicare UPIN