Provider Demographics
NPI:1528047503
Name:CLARK, WILLIAM GILMER (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:GILMER
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12418 DUNARD ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-6959
Mailing Address - Country:US
Mailing Address - Phone:919-554-8868
Mailing Address - Fax:
Practice Address - Street 1:2115 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-5011
Practice Address - Country:US
Practice Address - Phone:919-570-2000
Practice Address - Fax:919-570-2001
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24323207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC83247Medicare UPIN