Provider Demographics
NPI:1417950734
Name:CLARK, DELLIE H (MD)
Entity Type:Individual
Prefix:
First Name:DELLIE
Middle Name:H
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:312 GRAMMONT ST
Mailing Address - Street 2:STE 300
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7403
Mailing Address - Country:US
Mailing Address - Phone:318-388-4030
Mailing Address - Fax:318-324-3334
Practice Address - Street 1:417 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5325
Practice Address - Country:US
Practice Address - Phone:318-388-4030
Practice Address - Fax:318-324-3334
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA011665207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1171611Medicaid
LA5K009C148Medicare PIN
LA1171611Medicaid