Provider Demographics
NPI:1467515171
Name:CLARK, CHRISTINA LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:LOUISE
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 1:3130 GRATIOT AVENUE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207
Mailing Address - Country:US
Mailing Address - Phone:313-579-1860
Mailing Address - Fax:313-579-0017
Practice Address - Street 1:3130 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2283
Practice Address - Country:US
Practice Address - Phone:313-579-1860
Practice Address - Fax:313-922-0917
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083926207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MII35299Medicare UPIN