Basic Information
| Provider Information | |||||||||
| NPI: | 1790898450 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | VONDELL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | ATTN CREDENTIALING | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376620009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238572093 | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 FAIRVIEW ROAD | ||||||||
| Address2: | STE 230 | ||||||||
| City: | MOORESEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233437018 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 03/16/2019 | ||||||||
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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 | 207Q00000X | 9800216 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9800216 | 01 | NC | LICENSE - NC | OTHER | 1790898450 | 05 | NC | MEDICAID | BC5458624 | 01 | NC | DEA - NC | OTHER | 11521 | 01 | NC | BCBS PROVIDER NUMBER | OTHER |