Provider Demographics
NPI:1174887004
Name:CLARK, IRIS KALIN (MD)
Entity type:Individual
Prefix:
First Name:IRIS
Middle Name:KALIN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1550 BRAMPTON AVE
Mailing Address - Street 2:STE B
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0886
Mailing Address - Country:US
Mailing Address - Phone:912-623-2155
Mailing Address - Fax:912-623-2156
Practice Address - Street 1:1550 BRAMPTON AVE
Practice Address - Street 2:STE B
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0886
Practice Address - Country:US
Practice Address - Phone:912-623-2155
Practice Address - Fax:912-623-5156
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA73272207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine