Provider Demographics
NPI:1205199528
Name:CLARK, BLAIR YOUNG (DO)
Entity Type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:YOUNG
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MS
Other - First Name:BLAIR
Other - Middle Name:KATHERINE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:60 ASHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-1908
Mailing Address - Country:US
Mailing Address - Phone:419-448-8811
Mailing Address - Fax:419-448-7418
Practice Address - Street 1:60 ASHWOOD DR
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-1908
Practice Address - Country:US
Practice Address - Phone:419-448-8811
Practice Address - Fax:419-448-7418
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.012724207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0218698Medicaid