Provider Demographics
NPI:1346216389
Name:CLARK, JULIE D (MD)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1550 PROFESSIONAL DR STE A
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6655
Mailing Address - Country:US
Mailing Address - Phone:707-763-2900
Mailing Address - Fax:707-763-2990
Practice Address - Street 1:1550 PROFESSIONAL DR STE A
Practice Address - Street 2:SUITE 100
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6655
Practice Address - Country:US
Practice Address - Phone:707-763-2900
Practice Address - Fax:707-763-2990
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2021-10-20
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Provider Licenses
StateLicense IDTaxonomies
NY231988207V00000X
CAA98041207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABQ849YMedicare PIN