Provider Demographics
NPI:1275727927
Name:CLARK, STEPHEN DENNIS (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DENNIS
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 1:493 LANTANA RD
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-4946
Mailing Address - Country:US
Mailing Address - Phone:931-335-9919
Mailing Address - Fax:931-335-9954
Practice Address - Street 1:493 LANTANA RD
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4946
Practice Address - Country:US
Practice Address - Phone:931-335-9919
Practice Address - Fax:931-335-9954
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42144207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN42144OtherTN MEDICAL LICENSE
TN3000928Medicaid
KY7100432890Medicaid
TN103I115863Medicare PIN