MEDICARE: JOSEPH M CLARK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207YX0007X	Plastic Surgery within the Head & Neck (Otolaryngology) Physician	9700217	NC
2	207Y00000X	Otolaryngology Physician	9700217	NC

General Provider Information

NPI Number	:	1053308288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH M CLARK MD

Provider Business Mailing Address
First Line	:	PO BOX 24848
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27114-4848
Country	:	US
Telephone Number	:	336-538-1966
Fax Number	:	336-538-1729

Provider Business Practice Location Address
First Line	:	1248 HUFFMAN MILL RD
Second Line	:	STE 201
City	:	BURLINGTON
State	:	NC
Zip	:	27215-8700
Country	:	US
Telephone Number	:	336-538-1966
Fax Number	:	336-538-1729

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	04/30/2021

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