Provider Demographics
NPI:1194798595
Name:CLARK, JOHN DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DOUGLAS
Last Name:CLARK
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:PO BOX 4276
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29305
Mailing Address - Country:US
Mailing Address - Phone:864-582-6858
Mailing Address - Fax:864-585-0999
Practice Address - Street 1:2030 NORTH CHURCH PLACE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303
Practice Address - Country:US
Practice Address - Phone:864-582-6858
Practice Address - Fax:864-585-0999
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19596207RP1001X, 207R00000X, 207RC0200X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT36609Medicaid
290011227OtherRAILROAD
290009501OtherRAILROAD
SC8688OtherMBPG'S
SCT36609Medicaid
A98614Medicare UPIN
290009501OtherRAILROAD
SCAA6565019Medicare PIN