Provider Demographics
NPI:1275739286
Name:CLARK, MARIE A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 W 44TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-3265
Mailing Address - Country:US
Mailing Address - Phone:617-997-8404
Mailing Address - Fax:
Practice Address - Street 1:10524 EUCLID AVE STE 3150
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106
Practice Address - Country:US
Practice Address - Phone:216-844-3230
Practice Address - Fax:216-201-5188
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1239622080P0006X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics