Provider Demographics
NPI:1972712834
Name:CLARK, JAMES HOWARD JR (CMT)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:HOWARD
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5107 MARTIN DR
Mailing Address - Street 2:
Mailing Address - City:OXON HILL
Mailing Address - State:MD
Mailing Address - Zip Code:20745-3755
Mailing Address - Country:US
Mailing Address - Phone:301-630-1397
Mailing Address - Fax:
Practice Address - Street 1:13629 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5095
Practice Address - Country:US
Practice Address - Phone:301-617-0163
Practice Address - Fax:301-617-0165
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM01789171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor