Healthcare Provider Details

I. General information

NPI: 1972931533
Provider Name (Legal Business Name): SHAWN CLARK, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 AIRPORT BLVD #C138
MOBILE AL
36608-6705
US

IV. Provider business mailing address

6701 AIRPORT BLVD #C138
MOBILE AL
36608-6705
US

V. Phone/Fax

Practice location:
  • Phone: 251-295-2579
  • Fax:
Mailing address:
  • Phone: 251-295-2579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number23993
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number143
License Number StateAL

VIII. Authorized Official

Name: DR. SHAWN BROXTON CLARK
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 251-295-2579