Provider Demographics
NPI:1518901297
Name:CLARK, CATHERINE
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31218
Mailing Address - Street 2:OBGYN ASSOCIATES AT LICH
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06150-1219
Mailing Address - Country:US
Mailing Address - Phone:914-328-4500
Mailing Address - Fax:845-565-6057
Practice Address - Street 1:97 AMITY ST
Practice Address - Street 2:OBGYN ASSOCIATES AT LICH
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201
Practice Address - Country:US
Practice Address - Phone:718-790-1394
Practice Address - Fax:718-790-4987
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000506176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02230564Medicaid
NY02230564Medicaid
Q04520Medicare UPIN