1205199528 NPI number — DR. BLAIR YOUNG CLARK D.O.

Table of content: DR. BLAIR YOUNG CLARK D.O. (NPI 1205199528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205199528 NPI number — DR. BLAIR YOUNG CLARK D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
BLAIR
Provider Middle Name:
YOUNG
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YOUNG
Provider Other First Name:
BLAIR
Provider Other Middle Name:
KATHERINE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1205199528
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 ASHWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIFFIN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44883-1908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-448-8811
Provider Business Mailing Address Fax Number:
419-448-7418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 ASHWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIFFIN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44883-1908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-448-8811
Provider Business Practice Location Address Fax Number:
419-448-7418
Provider Enumeration Date:
06/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  34.012724 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0218698 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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