Provider Demographics
NPI:1609385566
Name:CLARK, KRYSTAL
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6960 ERIE DR
Mailing Address - Street 2:
Mailing Address - City:MAINEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45039-5105
Mailing Address - Country:US
Mailing Address - Phone:513-240-2892
Mailing Address - Fax:
Practice Address - Street 1:6960 ERIE DR
Practice Address - Street 2:
Practice Address - City:MAINEVILLE
Practice Address - State:OH
Practice Address - Zip Code:45039-5105
Practice Address - Country:US
Practice Address - Phone:513-240-2892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH560296207U00000X
OH040877207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine