Provider Demographics
NPI:1366651804
Name:CLARK, ANNEMARIE B (DO)
Entity Type:Individual
Prefix:DR
First Name:ANNEMARIE
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ANNEMARIE
Other - Middle Name:B
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:700 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1455
Mailing Address - Country:US
Mailing Address - Phone:419-563-9875
Mailing Address - Fax:
Practice Address - Street 1:512 HILL ST
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-1554
Practice Address - Country:US
Practice Address - Phone:419-563-9875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.009695207V00000X
OH58-002245207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050517Medicaid
OHPENDINGMedicaid