Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 000674 | GA |
Y | 222Z00000X | Podiatrist | 000674 | GA |
NPI | 1063428563 |
---|---|
Provider Name | Clark Alan Bernie |
First Address | Columbus, GA 31901-3600 |
Second Address | Columbus, GA 31901-3600 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2006 |
Last Update Date | 14/08/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
005155891 | (05) | GA |
U28440 | (02) |