Provider Demographics
NPI:1962704999
Name:CLARK, CHRISTOPHER E (DO)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:E
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
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 1007
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-1007
Mailing Address - Country:US
Mailing Address - Phone:601-766-0308
Mailing Address - Fax:601-766-0309
Practice Address - Street 1:57 DEWEY ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-5707
Practice Address - Country:US
Practice Address - Phone:601-766-0308
Practice Address - Fax:601-766-0309
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-00328208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS909150OtherMEDICARE
MS05788788Medicaid