Provider Demographics
NPI:1063428563
Name:BERNIE, CLARK ALAN (DPM)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:ALAN
Last Name:BERNIE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 10TH AVE
Mailing Address - Street 2:STE 120
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-3600
Mailing Address - Country:US
Mailing Address - Phone:706-323-6914
Mailing Address - Fax:706-596-1281
Practice Address - Street 1:1900 10TH AVE
Practice Address - Street 2:STE 120
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3600
Practice Address - Country:US
Practice Address - Phone:706-323-6914
Practice Address - Fax:706-596-1281
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000674213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA005155891Medicaid
GA6012630001Medicare NSC
U28440Medicare UPIN
GA48SCBLDMedicare ID - Type Unspecified