Provider Demographics
NPI:1407814726
Name:CLARK, TIMOTHY A (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 MILLENNIUM WAY
Mailing Address - Street 2:STE 400
Mailing Address - City:ENOLA
Mailing Address - State:PA
Mailing Address - Zip Code:17025
Mailing Address - Country:US
Mailing Address - Phone:717-724-2791
Mailing Address - Fax:717-724-2797
Practice Address - Street 1:2250 MILLENNIUM WAY
Practice Address - Street 2:STE 400
Practice Address - City:ENOLA
Practice Address - State:PA
Practice Address - Zip Code:17025
Practice Address - Country:US
Practice Address - Phone:717-724-2791
Practice Address - Fax:717-724-2797
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067096L207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001821036Medicaid
H23114Medicare UPIN
040611Medicare ID - Type Unspecified