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NPI Code Detail

MEDICARE: DR. GARY WAYNE CLARK D.O.

MEDICARE: DR. GARY WAYNE CLARK D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine PhysicianDO785TN
2207Q00000XFamily Medicine Physician011418OH

General Provider Information

NPI Number : 1013987759
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. GARY WAYNE CLARK D.O.
Provider Business Mailing Address
First Line : 82 5TH ST NE
Second Line :
City : CARROLLTON
State : OH
Zip : 44615-1214
Country : US
Telephone Number : 330-627-3494
Fax Number : 330-627-3494
Provider Business Practice Location Address
First Line : 125 CANTON RD NW
Second Line :
City : CARROLLTON
State : OH
Zip : 44615-1009
Country : US
Telephone Number : 330-627-7641
Fax Number : 330-627-5796
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/25/2006
Last Update Date : 04/24/2015

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