Provider Demographics
NPI:1730137209
Name:CLARK, DEBORAH Y (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:Y
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 PINE HEIGHTS AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5208
Mailing Address - Country:US
Mailing Address - Phone:410-644-2582
Mailing Address - Fax:410-644-6232
Practice Address - Street 1:1221 MERCANTILE LN
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-5374
Practice Address - Country:US
Practice Address - Phone:301-618-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072948A207V00000X
MDD78154207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHF39092Medicare UPIN
OHF39092Medicare UPIN
FL004390100Medicaid