Provider Demographics
NPI:1558866251
Name:CLARK, SOPHIE E (MD)
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:E
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 1:2600 GREEN RD STE 150-B
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-4631
Mailing Address - Country:US
Mailing Address - Phone:734-764-3186
Mailing Address - Fax:
Practice Address - Street 1:1635 AURORA CT FL 5
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2541
Practice Address - Country:US
Practice Address - Phone:720-848-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0068811207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine