Provider Demographics
NPI:1346566700
Name:CLARK, LATOYA SHANTEL (MD)
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:SHANTEL
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 1:1758 PARK PL
Mailing Address - Street 2:SUITE 406
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1127
Mailing Address - Country:US
Mailing Address - Phone:251-716-4744
Mailing Address - Fax:
Practice Address - Street 1:1758 PARK PL
Practice Address - Street 2:SUITE 406
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1127
Practice Address - Country:US
Practice Address - Phone:251-716-4744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.33558207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL2106252Medicaid