MEDICARE: DOUGLAS CLARK

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
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	DB1921	OTHER		RAILROAD MCARE

General Provider Information

NPI Number	:	1487756755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOUGLAS CLARK

Provider Business Mailing Address
First Line	:	2317 SOUTH ROANE STREET
Second Line	:
City	:	HARRIMAN
State	:	TN
Zip	:	37748
Country	:	US
Telephone Number	:	865-590-0072
Fax Number	:	865-590-0069

Provider Business Practice Location Address
First Line	:	2317 SOUTH ROANE STREET
Second Line	:
City	:	HARRIMAN
State	:	TN
Zip	:	37748
Country	:	US
Telephone Number	:	865-590-0072
Fax Number	:	865-590-0069

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DOUGLAS MARLEY CLARK
Credential	:	PAC
Telephone Number	:	865-590-0072

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	08/22/2020

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Directions to “DOUGLAS CLARK ” Practice Location

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