Provider Demographics
NPI:1063403434
Name:RAY, WESLEY CLARK (MD)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:CLARK
Last Name:RAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 22ND AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1852
Mailing Address - Country:US
Mailing Address - Phone:629-255-3486
Mailing Address - Fax:
Practice Address - Street 1:222 22ND AVE N
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1852
Practice Address - Country:US
Practice Address - Phone:629-255-2153
Practice Address - Fax:629-255-4041
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD019992207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ018215Medicaid
TN3065839Medicaid
TNF19261Medicare UPIN
TNQ018215Medicaid