Provider Demographics
NPI:1669765756
Name:CLARK, TIMOTHY ADAM (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ADAM
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 1:304 SHORTER AVE NW
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-4290
Mailing Address - Country:US
Mailing Address - Phone:706-509-3334
Mailing Address - Fax:706-509-4272
Practice Address - Street 1:304 SHORTER AVE NW
Practice Address - Street 2:SUITE 201
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-4290
Practice Address - Country:US
Practice Address - Phone:706-509-3334
Practice Address - Fax:706-509-4272
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA69566207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134531DMedicaid
GA003134531EMedicaid
GA003134531CMedicaid
GA003134531AMedicaid
GA003134531BMedicaid
GA003134531FMedicaid