1750449252 NPI number — KATHRYN M CLARK OD

Table of content: KATHRYN M CLARK OD (NPI 1750449252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750449252 NPI number — KATHRYN M CLARK OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
KATHRYN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750449252
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
617 GLENHITE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHEELING
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26003-6611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-233-1482
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 JACOB ST. SUITE 201
Provider Second Line Business Practice Location Address:
VALLEY PROF. CENTER SOUTH
Provider Business Practice Location Address City Name:
WHEELING
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26003-6390
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-242-9245
Provider Business Practice Location Address Fax Number:
304-242-6870
Provider Enumeration Date:
12/05/2006

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: 152W00000X , with the licence number:  831-OD , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DG8768 . This is a "RAILROAD MEDICARE WV GROUP PIN" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: DG5587 . This is a "RAILROAD MEDICARE GROUP OH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0149721000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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