Basic Information
| Provider Information | |||||||||
| NPI: | 1952578460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5213 S ALSTON AVE | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277134430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196204917 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2100 ERWIN RD | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277053941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196848111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2008 | ||||||||
| LastUpdateDate: | 07/03/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 243377 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 2012-00214 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.