Provider Demographics
NPI:1215977889
Name:CLARK, GEORGE THOMAS III (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:THOMAS
Last Name:CLARK
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3713 BENSON DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7372
Mailing Address - Country:US
Mailing Address - Phone:919-235-3400
Mailing Address - Fax:919-235-3401
Practice Address - Street 1:3713 BENSON DRIVE, SUITE 201
Practice Address - Street 2:CAROLINA VASCULAR SURGERY & DIAGNOSTICS, PA
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7372
Practice Address - Country:US
Practice Address - Phone:919-235-3400
Practice Address - Fax:919-235-3401
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC32073174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC803254OtherPARTNERS MEDICARE
NCP00016339OtherMEDICARE RAILROAD
NC3750391OtherUNITEDHEALTHCARE
NC8922713Medicaid
NC22713OtherBLUE CROSS/BLUE SHIELD
NC424855OtherAETNA
NCC6338OtherMEDCOST
NC212051DMedicare ID - Type Unspecified
NC3750391OtherUNITEDHEALTHCARE