Provider Demographics
NPI:1528034600
Name:CLARK, REBECCA S (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:S
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 1:340 OXFORD ST
Mailing Address - Street 2:#110
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-1965
Mailing Address - Country:US
Mailing Address - Phone:330-343-0753
Mailing Address - Fax:330-343-4787
Practice Address - Street 1:340 OXFORD ST
Practice Address - Street 2:#110
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-1965
Practice Address - Country:US
Practice Address - Phone:330-343-0753
Practice Address - Fax:330-343-4787
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062614207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0911213Medicaid
OHCL0846941Medicare PIN
OH0911213Medicaid