Basic Information
| Provider Information | |||||||||
| NPI: | 1194773457 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | HUSTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 E WENDOVER AVE | ||||||||
| Address2: | STE 311 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362726161 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 301 E WENDOVER AVE | ||||||||
| Address2: | STE 311 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362726161 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 04/15/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 200500021 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0206X | 200500021 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 5900510 | 05 | NC | MEDICAID | 1386T | 01 | NC | BCBS NC | OTHER | 4304710 | 01 | NC | AETNA | OTHER | B1041 | 01 | NC | MEDCOST | OTHER |