Basic Information
| Provider Information | |||||||||
| NPI: | 1578531935 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONOUGH | ||||||||
| FirstName: | CLARK | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062726000 | ||||||||
| FaxNumber: | 7062726049 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062726000 | ||||||||
| FaxNumber: | 7062726049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 07/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 54813 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.