Provider Demographics
NPI:1033616032
Name:CLARK, ABIGAIL
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 GILMAN DR # 851
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92093-5004
Mailing Address - Country:US
Mailing Address - Phone:571-228-8139
Mailing Address - Fax:
Practice Address - Street 1:9500 GILMAN DR # 9116A
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093
Practice Address - Country:US
Practice Address - Phone:619-471-0259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-07
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1655542084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry