Provider Demographics
NPI:1679667174
Name:CLARK, HAL CLIFORD (MD)
Entity type:Individual
Prefix:
First Name:HAL
Middle Name:CLIFORD
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 SHEFFEY DR
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551
Mailing Address - Country:US
Mailing Address - Phone:434-239-8104
Mailing Address - Fax:434-239-4312
Practice Address - Street 1:21556 TIMBERLAKE RD
Practice Address - Street 2:SUITE D
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502
Practice Address - Country:US
Practice Address - Phone:434-239-8104
Practice Address - Fax:434-239-4312
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040584207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA110058961OtherRAILROAD MEDICARE
VA006049711Medicaid
VA035241OtherANTHEM
VAC47057Medicare UPIN
VA006049711Medicaid