Provider Demographics
NPI:1659355113
Name:CLARK, LAURENCE J (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8101 HINSON FARM RD
Mailing Address - Street 2:#119
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-3403
Mailing Address - Country:US
Mailing Address - Phone:703-799-7300
Mailing Address - Fax:703-799-8767
Practice Address - Street 1:8101 HINSON FARM RD
Practice Address - Street 2:#119
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3403
Practice Address - Country:US
Practice Address - Phone:703-799-7300
Practice Address - Fax:703-799-8767
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2009-12-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101030440207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA065941OtherANTHEM HEALTHKEEPERS
DC409113518OtherPALMETTO MEDICARE RAILROAD
VA6086659Medicaid
VA065941OtherANTHEM HEALTHKEEPERS
VA6086659Medicaid