Provider Demographics
NPI:1164836557
Name:CLARK, KATHLEEN (DO)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6174
Mailing Address - Fax:
Practice Address - Street 1:1234 NAPIER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-982-4941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021292207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine