Provider Demographics
NPI:1578776217
Name:CLARK, KEVIN L (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
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 1:2772 RUTLAND RD
Mailing Address - Street 2:
Mailing Address - City:DAVIDSONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21035-1228
Mailing Address - Country:US
Mailing Address - Phone:410-721-2273
Mailing Address - Fax:410-798-4069
Practice Address - Street 1:2772 RUTLAND RD
Practice Address - Street 2:
Practice Address - City:DAVIDSONVILLE
Practice Address - State:MD
Practice Address - Zip Code:21035-1228
Practice Address - Country:US
Practice Address - Phone:410-721-2273
Practice Address - Fax:410-798-4069
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD47201208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDBC4438316OtherDEA CERTIFICATE