Provider Demographics
NPI:1104814946
Name:PRITTS, CLARK E (DO)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:E
Last Name:PRITTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:910-754-4441
Mailing Address - Fax:910-754-5307
Practice Address - Street 1:5145 SELLERS RD
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-3405
Practice Address - Country:US
Practice Address - Phone:910-754-4441
Practice Address - Fax:910-754-5307
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009995207Q00000X
NC200401306207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC141H5OtherBCBS OF NC
NC5903932Medicaid
NC2344688HMedicare PIN
NC5903932Medicaid
NC2402987BMedicare PIN
NC141H5OtherBCBS OF NC