Provider Demographics
NPI:1821138397
Name:COBB, CLARA (MD)
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:COBB
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 1:227 ARROWHEAD TRL
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-7003
Mailing Address - Country:US
Mailing Address - Phone:865-376-4205
Mailing Address - Fax:
Practice Address - Street 1:227 ARROWHEAD TRL
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-7003
Practice Address - Country:US
Practice Address - Phone:865-376-4205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD18478207ZP0102X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7525265OtherCIGNA
TN134107OtherBLACK LUNG
TN1520556OtherUNITED MINE WORKERS
TN220019758OtherRR MEDICARE
TN76828OtherPHP CARITEN
TN62159OtherSIGNATURE HEALTH ALLIANCE
TN62-1658-77OtherTAX ID#
TN100021685OtherPHP TENNCARE
TN3048821OtherBLUE CROSS BLUE SHIELD TN
TNHEALTHSOURCEOther014F17649
TNMD18478OtherMEDICAL LICENSE #
TN621658077OtherCHAMPUS
TN621658077OtherCHAMPUS
TNF17649Medicare UPIN