Provider Demographics
NPI:1760460802
Name:CLARK, MARY HOLLAND HOBACK (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:HOLLAND HOBACK
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:HOLLY
Other - Middle Name:HOBACK
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1004
Mailing Address - Street 2:BARRON DR
Mailing Address - City:INSTITUTE
Mailing Address - State:WV
Mailing Address - Zip Code:25112-1004
Mailing Address - Country:US
Mailing Address - Phone:304-766-4855
Mailing Address - Fax:304-766-4954
Practice Address - Street 1:BARRON DR
Practice Address - Street 2:
Practice Address - City:INSTITUTE
Practice Address - State:WV
Practice Address - Zip Code:25112-1004
Practice Address - Country:US
Practice Address - Phone:304-766-4855
Practice Address - Fax:304-766-4954
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV108922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0116792000Medicaid
WV10892OtherWV BD OF MEDECINE
WVA72156Medicare UPIN
WV7180691Medicare ID - Type UnspecifiedMEDICARE B PROVIDER