Provider Demographics
NPI:1861458267
Name:CLARK, CATHERINE LEAH (VA)
Entity Type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:LEAH
Last Name:CLARK
Suffix:
Gender:F
Credentials:VA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 FETTLER PARK
Mailing Address - Street 2:DUMFRIES HEALTH CENTER
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22025
Mailing Address - Country:US
Mailing Address - Phone:703-441-7500
Mailing Address - Fax:
Practice Address - Street 1:3700 FETTLER PARK
Practice Address - Street 2:DUMFRIES HEALTH CENTER
Practice Address - City:DUMFRIES
Practice Address - State:VA
Practice Address - Zip Code:22025
Practice Address - Country:US
Practice Address - Phone:703-441-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101029558207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101029558OtherSTATE LICENSE
A03586Medicare UPIN