Provider Demographics
NPI:1861676538
Name:CLARK-WHITE, CORDIA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:CORDIA
Middle Name:MARIE
Last Name:CLARK-WHITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CORDIA
Other - Middle Name:MARIE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3473 S KING DR # 472
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4108
Mailing Address - Country:US
Mailing Address - Phone:708-207-3639
Mailing Address - Fax:
Practice Address - Street 1:1645 W JACKSON BLVD STE 310
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3227
Practice Address - Country:US
Practice Address - Phone:312-942-8060
Practice Address - Fax:312-942-8222
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-119447207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619478OtherBLUE CROSS BLUE SHIELD
IL036119447Medicaid
IL141878Medicare Oscar/Certification