Healthcare Provider Details

I. General information

NPI: 1386673838
Provider Name (Legal Business Name): CLARK DOUGLAS WITHERSPOON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 UNIVERSITY BLVD SUITE 601
BIRMINGHAM AL
35294-0009
US

IV. Provider business mailing address

1720 UNIVERSITY BLVD SUITE 601
BIRMINGHAM AL
35294-0009
US

V. Phone/Fax

Practice location:
  • Phone: 205-325-8620
  • Fax: 205-558-2553
Mailing address:
  • Phone: 205-325-8620
  • Fax: 205-558-2553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number8455
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: