Provider Demographics
NPI:1922014182
Name:CLARK, ELIZABETH CATHERINE (DO)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CATHERINE
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:PO BOX 860
Mailing Address - Street 2:
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:
Practice Address - Street 1:200 W. HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941
Practice Address - Country:US
Practice Address - Phone:928-338-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1346204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1629236716Medicaid
AZ1780614008Medicaid
AZ1871523191Medicaid
AZ1295993376Medicaid
AZ409757Medicaid
AZ1629236716Medicaid
AZ1780614008Medicaid
AZ1871523191Medicaid