Provider Demographics
NPI:1336107762
Name:CLARK, MARK W X (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:CLARK
Suffix:X
Gender:M
Credentials:MD
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Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:2112 HARTFORD RD
Practice Address - Street 2:SUITE B
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6601
Practice Address - Country:US
Practice Address - Phone:757-827-7754
Practice Address - Fax:757-838-3692
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-05-05
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Provider Licenses
StateLicense IDTaxonomies
VA0101028804207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1336107762Medicaid
VA015946R53Medicare PIN
VA1336107762Medicaid
VAP0061019Medicare PIN