1356315428 NPI number — DEANDRA L CLARK MD

Table of content: DEANDRA L CLARK MD (NPI 1356315428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356315428 NPI number — DEANDRA L CLARK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
DEANDRA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1356315428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 N FANT ST
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
ANDERSON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29621-5702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-225-7798
Provider Business Mailing Address Fax Number:
864-512-3952

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 N FANT ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
ANDERSON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29621-5702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-225-7798
Provider Business Practice Location Address Fax Number:
864-512-3952
Provider Enumeration Date:
02/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  ME76610 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: TL32184 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 258609600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com