Provider Demographics
NPI:1023009016
Name:LARK, KIM P (DO)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:P
Last Name:LARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 W PIERCE ST
Mailing Address - Street 2:SUITE 4-A
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3537
Mailing Address - Country:US
Mailing Address - Phone:575-234-9964
Mailing Address - Fax:575-234-9962
Practice Address - Street 1:2402 W PIERCE ST
Practice Address - Street 2:SUITE 4-A
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3537
Practice Address - Country:US
Practice Address - Phone:575-234-9964
Practice Address - Fax:575-234-9962
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA110698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMT9592Medicaid
NM4763430001Medicare ID - Type UnspecifiedDMER
NMT9592Medicaid
NM900521044Medicare PIN
NM080145241Medicare ID - Type UnspecifiedRAILROAD MEDICARE ID #