Provider Demographics
NPI:1649404625
Name:CLARK, BEVERLY MARIE (MD)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:309 SANDERS ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:66839-2616
Mailing Address - Country:US
Mailing Address - Phone:620-364-5395
Mailing Address - Fax:620-364-8719
Practice Address - Street 1:1004 E. MADISON ST
Practice Address - Street 2:
Practice Address - City:YATES CENTER
Practice Address - State:KS
Practice Address - Zip Code:66783-1314
Practice Address - Country:US
Practice Address - Phone:620-625-2312
Practice Address - Fax:620-625-3560
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-34503207Q00000X
KS94-07126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200969130CMedicaid