Healthcare Provider Details

I. General information

NPI: 1053474080
Provider Name (Legal Business Name): EDWARD JOSEPH CLARK III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 S. TARBORO ST
WILSON NC
27893
US

IV. Provider business mailing address

PO BOX 12156
NEWPORT NEWS VA
23612-2156
US

V. Phone/Fax

Practice location:
  • Phone: 252-399-8928
  • Fax: 252-399-7313
Mailing address:
  • Phone: 757-867-6101
  • Fax: 757-867-6588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number200101028
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number200101028
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: