Provider Demographics
NPI:1487756755
Name:DOUGLAS CLARK
Entity type:Organization
Organization Name:DOUGLAS CLARK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:MARLEY
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:865-590-0072
Mailing Address - Street 1:2317 SOUTH ROANE STREET
Mailing Address - Street 2:
Mailing Address - City:HARRIMAN
Mailing Address - State:TN
Mailing Address - Zip Code:37748
Mailing Address - Country:US
Mailing Address - Phone:865-590-0072
Mailing Address - Fax:865-590-0069
Practice Address - Street 1:2317 SOUTH ROANE STREET
Practice Address - Street 2:
Practice Address - City:HARRIMAN
Practice Address - State:TN
Practice Address - Zip Code:37748
Practice Address - Country:US
Practice Address - Phone:865-590-0072
Practice Address - Fax:865-590-0069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3723702Medicaid
DB1921OtherRAILROAD MCARE
DB1921OtherRAILROAD MCARE