Provider Demographics
NPI:1043219140
Name:CLARK, REBECCA ADAIR (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ADAIR
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 1:3308 TULANE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-7100
Mailing Address - Country:US
Mailing Address - Phone:504-982-0628
Mailing Address - Fax:504-903-5313
Practice Address - Street 1:3308 TULANE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-7100
Practice Address - Country:US
Practice Address - Phone:504-903-7302
Practice Address - Fax:504-903-5313
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.018089207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1392847Medicaid
MS00125805Medicaid
LA5K246F669Medicare PIN
LA440002091Medicare PIN
MS00125805Medicaid
LA5K246Medicare PIN