Provider Demographics
NPI:1790100113
Name:CLARK, COURTNEY A (DO)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:2274 HIGHWAY 43 S
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-8141
Practice Address - Country:US
Practice Address - Phone:601-347-9024
Practice Address - Fax:601-798-5914
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-21
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1790100113208000000X
MS29407208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics