Provider Demographics
NPI:1578613030
Name:CLARK, MARISOL C (MD)
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-6200
Mailing Address - Fax:859-258-6203
Practice Address - Street 1:1138 LEXINGTON RD STE 290
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9672
Practice Address - Country:US
Practice Address - Phone:502-863-0721
Practice Address - Fax:502-863-6104
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2023-08-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY49101207QA0401X, 207Q00000X, 207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100443440Medicaid