Provider Demographics
NPI:1316213234
Name:CLARK, BRIAN CHRISTOPHER (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHRISTOPHER
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 N GEORGE MASON DR STE 354
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-3687
Mailing Address - Country:US
Mailing Address - Phone:703-717-7780
Mailing Address - Fax:703-717-7781
Practice Address - Street 1:1625 N GEORGE MASON DR STE 354
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3687
Practice Address - Country:US
Practice Address - Phone:703-717-7780
Practice Address - Fax:703-717-7781
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.148415207RC0000X
VA0101272275207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS062-0584OtherCAREFIRST BC/BS
MD555206100Medicaid