Provider Demographics
NPI:1538117528
Name:CLARK, CURTIS E JR (DO)
Entity type:Individual
Prefix:
First Name:CURTIS
Middle Name:E
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 MANCHESTER EXPY STE 2001A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-6802
Mailing Address - Country:US
Mailing Address - Phone:706-320-3126
Mailing Address - Fax:706-320-3054
Practice Address - Street 1:610 19TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1528
Practice Address - Country:US
Practice Address - Phone:706-320-3126
Practice Address - Fax:706-320-3054
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047068207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000893538LMedicaid
GA202I930734Medicare PIN
GA000893538LMedicaid
GAH10877Medicare UPIN
GA000893538KMedicaid