Provider Demographics
NPI:1639156284
Name:CLARK, RITCHIE L (MD)
Entity Type:Individual
Prefix:
First Name:RITCHIE
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:PO BOX 22171
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-2171
Mailing Address - Country:US
Mailing Address - Phone:812-471-1591
Mailing Address - Fax:812-471-6650
Practice Address - Street 1:811 E PARRISH AVE
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3258
Practice Address - Country:US
Practice Address - Phone:270-688-2936
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21610207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64216104Medicaid
KY64216104Medicaid
C68416Medicare UPIN