Provider Demographics
NPI:1568509685
Name:CLARK, KENDALL R (MD)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:R
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 SW MAYNARD RD STE 150
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-4472
Mailing Address - Country:US
Mailing Address - Phone:919-578-8593
Mailing Address - Fax:
Practice Address - Street 1:119 SW MAYNARD RD STE 150
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-4472
Practice Address - Country:US
Practice Address - Phone:919-578-8593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65017207Q00000X
NC200200101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine