Provider Demographics
NPI:1932510377
Name:CLARK, SAMANTHA IRENE (IDC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:IRENE
Last Name:CLARK
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 851 BOX 340
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09834-0004
Mailing Address - Country:US
Mailing Address - Phone:508-361-7875
Mailing Address - Fax:
Practice Address - Street 1:PSC 851 BOX 340
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09834-0004
Practice Address - Country:US
Practice Address - Phone:318-439-9053
Practice Address - Fax:318-439-9053
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman