MEDICARE: BRADLEY WALTON 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	207R00000X	Internal Medicine Physician	2015-00428	NC
2	207R00000X	Internal Medicine Physician	LL34733	SC
3	207RC0000X	Cardiovascular Disease Physician	2015-00428	NC
4	207UN0901X	Nuclear Cardiology Physician	2015-00428	NC

General Provider Information

NPI Number	:	1639431307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY WALTON CLARK MD

Provider Business Mailing Address
First Line	:	PO BOX 751803
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1803
Country	:	US
Telephone Number	:	336-277-2000
Fax Number	:	336-277-2050

Provider Business Practice Location Address
First Line	:	7114 VILLAGE MEDICAL CIR
Second Line	:
City	:	CLEMMONS
State	:	NC
Zip	:	27012-8004
Country	:	US
Telephone Number	:	336-893-2440
Fax Number	:	336-893-2470

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

Provider Enumeration Date	:	06/08/2012
Last Update Date	:	02/18/2021

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