Provider Demographics
NPI:1114928546
Name:CLARK, ELEANOR ANN (MD)
Entity Type:Individual
Prefix:MRS
First Name:ELEANOR
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELEANOR
Other - Middle Name:ANN
Other - Last Name:MOKRANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1780 E FLORENCE BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-4782
Mailing Address - Country:US
Mailing Address - Phone:520-381-6758
Mailing Address - Fax:520-381-6040
Practice Address - Street 1:1780 E FLORENCE BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-4782
Practice Address - Country:US
Practice Address - Phone:520-381-6758
Practice Address - Fax:520-381-6040
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16389207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ243139Medicaid
AZ243139Medicaid