Provider Demographics
NPI:1023031358
Name:CLARK, CAROL A (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
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 1:1130 MEDICAL ARTS BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46011-3431
Mailing Address - Country:US
Mailing Address - Phone:765-298-4282
Mailing Address - Fax:765-298-4989
Practice Address - Street 1:1130 MEDICAL ARTS BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3431
Practice Address - Country:US
Practice Address - Phone:765-298-4282
Practice Address - Fax:765-298-4989
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01030355A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00102150OtherRR MEDICARE
IN000000312561OtherANTHEM
IN200044780Medicaid
INP00102150OtherRR MEDICARE
INM400047880Medicare PIN
IN200044780Medicaid
INM400043151Medicare PIN