Provider Demographics
NPI:1952578460
Name:CLARK, ALICIA T (MD)
Entity type:Individual
Prefix:MISS
First Name:ALICIA
Middle Name:T
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:919-620-4917
Mailing Address - Fax:
Practice Address - Street 1:2100 ERWIN RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3941
Practice Address - Country:US
Practice Address - Phone:919-684-8111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA243377207R00000X
NC2012-00214207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine