=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831320431
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL ALBERT CLARK D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2009
-----------------------------------------------------
Last Update Date | 07/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8901 ROCKVILLE PIKE
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-295-4191
-----------------------------------------------------
Fax | 301-319-2993
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8901 ROCKVILLE PIKE
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20889-0004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-400-0604
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 0102202876
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 0102202876
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------