Provider Demographics
NPI:1639123995
Name:CLARK, CHRISTOPHER B (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:B
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5360
Mailing Address - Fax:740-446-5486
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5360
Practice Address - Fax:740-446-5486
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21461207K00000X
OH35-08-2565207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1810204000Medicaid
OH2434771Medicaid
OH000000181421OtherOH MEDICAID UNISON
OH2434771OtherOH MEDICAID MOLINA
OH310917085113OtherOH MEDICAID CARESOURCE
H62836Medicare UPIN
OHCL4114483Medicare PIN