Provider Demographics
NPI:1033156617
Name:CLARK, CAROLYN (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4461 STARKEY ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018
Mailing Address - Country:US
Mailing Address - Phone:540-345-4946
Mailing Address - Fax:540-982-7164
Practice Address - Street 1:4461 STARKEY ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018
Practice Address - Country:US
Practice Address - Phone:540-345-4946
Practice Address - Fax:540-343-7693
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057337207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5427630OtherAETNA
VA1033156617Medicaid
VA110165956OtherRAILROAD MEDICARE
VA294398OtherSOUTHERN HEALTH
VA7236246OtherCIGNA
VA393746OtherANTHEM
VA393746OtherANTHEM
F23559Medicare UPIN