Provider Demographics
NPI:1053433250
Name:CLARK, MATTHEW TAYLOR (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TAYLOR
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:130 ALLEN CT
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29860-9782
Mailing Address - Country:US
Mailing Address - Phone:803-279-7666
Mailing Address - Fax:803-279-0708
Practice Address - Street 1:616 EDGEFIELD RD
Practice Address - Street 2:SUITE 180
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-1938
Practice Address - Country:US
Practice Address - Phone:803-279-7666
Practice Address - Fax:803-279-0708
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA057156207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1053433250Medicaid