Provider Demographics
NPI:1972931533
Name:SHAWN CLARK, M.D., P.C.
Entity type:Organization
Organization Name:SHAWN CLARK, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:BROXTON
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-295-2579
Mailing Address - Street 1:6701 AIRPORT BLVD
Mailing Address - Street 2:#C138
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-6705
Mailing Address - Country:US
Mailing Address - Phone:251-295-2579
Mailing Address - Fax:
Practice Address - Street 1:6701 AIRPORT BLVD
Practice Address - Street 2:#C138
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-6705
Practice Address - Country:US
Practice Address - Phone:251-295-2579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-17
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23993174400000X
AL143363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty