Provider Demographics
NPI:1538194261
Name:CLARK, TERESA ELAINE (MD PC)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:ELAINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:667 LANIER PARK DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2059
Mailing Address - Country:US
Mailing Address - Phone:770-532-7501
Mailing Address - Fax:
Practice Address - Street 1:2920 S PHARR CT NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2104
Practice Address - Country:US
Practice Address - Phone:404-261-9043
Practice Address - Fax:404-581-5440
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020417207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00211758AMedicaid
GA00211758AMedicaid