Provider Demographics
NPI:1982608428
Name:CLARK, JAMES WARNER (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WARNER
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:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-0850
Mailing Address - Country:US
Mailing Address - Phone:423-257-8089
Mailing Address - Fax:423-257-5179
Practice Address - Street 1:105 LIMESTONE RURITAN RD
Practice Address - Street 2:
Practice Address - City:LIMESTONE
Practice Address - State:TN
Practice Address - Zip Code:37681-2515
Practice Address - Country:US
Practice Address - Phone:423-257-8089
Practice Address - Fax:423-257-5179
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15468207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3010178Medicaid
TN61386OtherBCBST
A97437Medicare UPIN
TN3010178Medicaid
080129161Medicare PIN
30101701Medicare PIN
3703861Medicare PIN
TN61386OtherBCBST
3010174Medicare ID - Type Unspecified