Healthcare Provider Details

I. General information

NPI: 1043620347
Provider Name (Legal Business Name): J MADISON CLARK MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1248 HUFFMAN MILL RD SUITE 201
BURLINGTON NC
27215-8700
US

IV. Provider business mailing address

PO BOX 24848
WINSTON SALEM NC
27114-4848
US

V. Phone/Fax

Practice location:
  • Phone: 336-538-1966
  • Fax: 336-538-1729
Mailing address:
  • Phone: 336-538-1966
  • Fax: 336-538-1729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number9700217
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number9700217
License Number StateNC

VIII. Authorized Official

Name: SONJA D THOMPSON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 336-538-1966