Provider Demographics
NPI:1528151164
Name:CLARK, PETER DOUGLAS (DC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:DOUGLAS
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 POPULAR TENT RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027
Mailing Address - Country:US
Mailing Address - Phone:704-792-2700
Mailing Address - Fax:704-792-2705
Practice Address - Street 1:3630 POPULAR TENT RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027
Practice Address - Country:US
Practice Address - Phone:704-792-2700
Practice Address - Fax:704-792-2705
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2391111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890825NMedicaid
NCU66366Medicare UPIN
NC890825NMedicare ID - Type Unspecified