Provider Demographics
NPI:1932306875
Name:CLARK, CHERYLL ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHERYLL
Middle Name:ANNE
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 1:2660 W COVELL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-5645
Mailing Address - Country:US
Mailing Address - Phone:530-747-3000
Mailing Address - Fax:
Practice Address - Street 1:2660 W COVELL BLVD STE B
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-5645
Practice Address - Country:US
Practice Address - Phone:530-747-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA146218208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics