Provider Demographics
NPI:1396830477
Name:CLARK, LIN W (MD)
Entity Type:Individual
Prefix:DR
First Name:LIN
Middle Name:W
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:7091 E SPEEDWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-1241
Mailing Address - Country:US
Mailing Address - Phone:520-721-5777
Mailing Address - Fax:
Practice Address - Street 1:7091 E SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-1241
Practice Address - Country:US
Practice Address - Phone:520-721-5777
Practice Address - Fax:520-298-7231
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ65768207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO18018041OtherBLUE CROSS BLUE SHIELD
168073OtherCOVENTRY
7896043OtherAETNA
MOR5P28OtherSTATE LICENSE NUMBER
MOR5P28OtherSTATE LICENSE NUMBER
MOP337176OtherMEDICARE ID