Provider Demographics
NPI:1477247864
Name:CLARK INFECTIOUS DISEASE GROUP
Entity Type:Organization
Organization Name:CLARK INFECTIOUS DISEASE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:P
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-582-1629
Mailing Address - Street 1:105 WATCH HARBOUR CT
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3179
Mailing Address - Country:US
Mailing Address - Phone:757-582-1629
Mailing Address - Fax:
Practice Address - Street 1:2220 EDWARD HOLLAND DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-2519
Practice Address - Country:US
Practice Address - Phone:757-582-1629
Practice Address - Fax:757-819-4995
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLARK ALLIANCE SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-06-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty