Provider Demographics
NPI:1538334933
Name:CLARK, SPURGEON WILLIAM III (M D)
Entity type:Individual
Prefix:
First Name:SPURGEON
Middle Name:WILLIAM
Last Name:CLARK
Suffix:III
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2009
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31502-2009
Mailing Address - Country:US
Mailing Address - Phone:912-285-2020
Mailing Address - Fax:912-285-8112
Practice Address - Street 1:502 ISABELLA STREET
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-3638
Practice Address - Country:US
Practice Address - Phone:912-285-2020
Practice Address - Fax:912-285-8112
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024916207W00000X
GA24916207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000264547BMedicaid
GA024581OtherBCBS
GA180011242OtherMEDICARE RR
GA180011242OtherMEDICARE RR
GA024581OtherBCBS