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General NPI Number Information
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NPI Number | 1962704999
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Entity Type | Individual
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Provider Name | CHRISTOPHER E CLARK D.O.
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Gender | Male
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Dates
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Enumeration Date | 11/23/2010
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Last Update Date | 02/06/2020
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Provider Practice Location Address
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Address Line | 57 DEWEY ST
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City | LUCEDALE
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State | MS
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Zip | 39452-5707
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Country | US
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Telephone | 601-766-0308
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Fax | 601-766-0309
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Provider Business Mailing Address
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Address Line | PO BOX 1007
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City | LUCEDALE
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State | MS
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Zip | 39452-1007
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Country | US
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Telephone | 601-766-0308
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Fax | 601-766-0309
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 2016-00328
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License Number State | NC
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