Healthcare Provider Details

I. General information

NPI: 1528047503
Provider Name (Legal Business Name): WILLIAM GILMER CLARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 10/25/2020
Certification Date: 09/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 S MAIN ST
WAKE FOREST NC
27587-5011
US

IV. Provider business mailing address

12418 DUNARD ST
RALEIGH NC
27614-6959
US

V. Phone/Fax

Practice location:
  • Phone: 919-570-2000
  • Fax: 919-570-2001
Mailing address:
  • Phone: 919-554-8868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24323
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: