Provider Demographics
NPI:1821151507
Name:CLARK, KAREN E (MD)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:E
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:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0897
Mailing Address - Country:US
Mailing Address - Phone:304-293-7401
Mailing Address - Fax:304-293-6963
Practice Address - Street 1:1 STADIUM DRIVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506
Practice Address - Country:US
Practice Address - Phone:304-598-4800
Practice Address - Fax:304-598-4871
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16288207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0075036000Medicaid
WV0075036000Medicaid
WVCL6024351Medicare ID - Type Unspecified