Provider Demographics
NPI:1528425360
Name:CLARK LASER & COSMETIC DERMATOLOGY, LLC
Entity type:Organization
Organization Name:CLARK LASER & COSMETIC DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-873-9956
Mailing Address - Street 1:20 10TH ST NW UNIT 901
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3867
Mailing Address - Country:US
Mailing Address - Phone:770-873-9956
Mailing Address - Fax:888-741-9391
Practice Address - Street 1:3200 DOWNWOOD CIR NW
Practice Address - Street 2:SUITE 360
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-1610
Practice Address - Country:US
Practice Address - Phone:770-405-9956
Practice Address - Fax:888-741-9391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64521207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty