Provider Demographics
NPI:1962406793
Name:CLARK, RICHARD GARY (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GARY
Last Name:CLARK
Suffix:
Gender:M
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 2861
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38557-2861
Mailing Address - Country:US
Mailing Address - Phone:931-879-5864
Mailing Address - Fax:931-879-3903
Practice Address - Street 1:100 S DUNCAN ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:TN
Practice Address - Zip Code:38556-3009
Practice Address - Country:US
Practice Address - Phone:931-879-5864
Practice Address - Fax:931-879-3903
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11080207P00000X, 208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4053283Medicaid
B04205Medicare UPIN
TN3185710Medicare ID - Type UnspecifiedTN MEDICARE