Provider Demographics
NPI:1205816394
Name:CLARK, KATHERINE J (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-475-8121
Mailing Address - Fax:336-475-5377
Practice Address - Street 1:309 PINEYWOOD RD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-3438
Practice Address - Country:US
Practice Address - Phone:336-475-8121
Practice Address - Fax:336-475-5377
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC9500536207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7922700Medicaid
NC7922700Medicaid
NC2214878DMedicare PIN
NC2214878CMedicare PIN
NC2214878EMedicare PIN
BC3199874OtherFEDERAL DEA