Basic Information
| Provider Information | |||||||||
| NPI: | 1225010754 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 925 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309030925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067248611 | ||||||||
| FaxNumber: | 7067246202 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 SAINT SEBASTIAN WAY | ||||||||
| Address2: | SUITE 311 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309012651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067243473 | ||||||||
| FaxNumber: | 7067243493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | 043579 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 597816 | 01 | GA | BCBS | OTHER | G43579 | 05 | SC | MEDICAID | 000749801A | 05 | GA | MEDICAID |