Provider Demographics
NPI:1386931509
Name:CLARK, AMY T (MD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:T
Last Name:CLARK
Suffix:
Gender:F
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 298
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35631-0298
Mailing Address - Country:US
Mailing Address - Phone:256-767-7494
Mailing Address - Fax:256-760-8432
Practice Address - Street 1:203 AVALON AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-2869
Practice Address - Country:US
Practice Address - Phone:256-383-6070
Practice Address - Fax:256-381-4022
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.34340207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03808531Medicaid
MSP01332517OtherRAILROAD MEDICARE
MS03808531Medicaid