Provider Demographics
NPI:1346236775
Name:CLARK, MELISSA AVIVA (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:AVIVA
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:800S FREDERICK AVE 100
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-4151
Mailing Address - Country:US
Mailing Address - Phone:301-355-2013
Mailing Address - Fax:301-963-0072
Practice Address - Street 1:9710 PATUXENT WOODS DR
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1526
Practice Address - Country:US
Practice Address - Phone:301-575-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-105536207Q00000X
MDD70056207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-105536Medicaid
IL036-105536Medicaid