Provider Demographics
NPI:1699798504
Name:CLARK, ANDREW D (MD, PHD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD, PHD
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 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-5880
Mailing Address - Fax:864-375-1347
Practice Address - Street 1:160 PERPETUAL SQ
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1713
Practice Address - Country:US
Practice Address - Phone:864-512-5880
Practice Address - Fax:864-375-1347
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-01153207V00000X
SC29173207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC291730Medicaid
GA003112203AMedicaid
GA003112203AMedicaid
SCAA77547111Medicare PIN
SCAA77547043Medicare PIN