1245412352 NPI number — H CLARK DERISO M.D.P.C.

Table of content: (NPI 1245412352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245412352 NPI number — H CLARK DERISO M.D.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
H CLARK DERISO M.D.P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245412352
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38 MEDICAL ARTS CTR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31405-4415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-692-0755
Provider Business Mailing Address Fax Number:
912-692-0754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
38 MEDICAL ARTS CENTER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31405-4155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-692-0755
Provider Business Practice Location Address Fax Number:
912-692-0754
Provider Enumeration Date:
11/30/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DERISO
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
CLARK
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
972-692-0755

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  013026 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)