Provider Demographics
NPI:1578692463
Name:CLARK, SANDRA (RT(R))
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RT(R)
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RT
Mailing Address - Street 1:139 COUNTY ROAD 379
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965-3607
Mailing Address - Country:US
Mailing Address - Phone:662-514-5215
Mailing Address - Fax:
Practice Address - Street 1:139 COUNTY ROAD 379
Practice Address - Street 2:
Practice Address - City:WATER VALLEY
Practice Address - State:MS
Practice Address - Zip Code:38965-3607
Practice Address - Country:US
Practice Address - Phone:662-514-5215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMRT22792471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09851011Medicaid