Provider Demographics
NPI:1043620347
Name:J MADISON CLARK MD PLLC
Entity type:Organization
Organization Name:J MADISON CLARK MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SONJA
Authorized Official - Middle Name:D
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-538-1966
Mailing Address - Street 1:PO BOX 24848
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-4848
Mailing Address - Country:US
Mailing Address - Phone:336-538-1966
Mailing Address - Fax:336-538-1729
Practice Address - Street 1:1248 HUFFMAN MILL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8700
Practice Address - Country:US
Practice Address - Phone:336-538-1966
Practice Address - Fax:336-538-1729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-07
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700217207Y00000X, 207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Single Specialty