Provider Demographics
NPI:1730423278
Name:CLARK, WILLIAM DOUGLAS
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:DOUGLAS
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 254
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-0254
Mailing Address - Country:US
Mailing Address - Phone:770-961-1947
Mailing Address - Fax:770-961-1947
Practice Address - Street 1:1617 HIGHWAY 20 W
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-7311
Practice Address - Country:US
Practice Address - Phone:770-961-1947
Practice Address - Fax:770-961-1947
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist