Provider Demographics
NPI:1245223056
Name:CLARK, ANDREW STONE (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:STONE
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 SANTA ROSA RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-5109
Mailing Address - Country:US
Mailing Address - Phone:804-288-4453
Mailing Address - Fax:804-288-1621
Practice Address - Street 1:1602 SKIPWITH RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-5205
Practice Address - Country:US
Practice Address - Phone:804-289-4937
Practice Address - Fax:804-565-6600
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101034102207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010156751Medicaid
VA00V362R94Medicare ID - Type Unspecified
VA010156751Medicaid