Provider Demographics
NPI:1942277652
Name:CLARK, VIVIAN ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:ELIZABETH
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 1:120 CONNER DRIVE
Mailing Address - Street 2:# 101
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514
Mailing Address - Country:US
Mailing Address - Phone:919-942-8571
Mailing Address - Fax:919-942-6355
Practice Address - Street 1:120 CONNER DR
Practice Address - Street 2:#101 CHAPEL HILL OB GYN
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514
Practice Address - Country:US
Practice Address - Phone:919-942-8571
Practice Address - Fax:919-942-6355
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30614207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC22171OtherBCBS
NC22179OtherMEDCOST
NC1284188003OtherUHC
NC154773OtherWELLPATH
NC7922717Medicaid
NC562142486OtherBEECHSTREET
NC2855944OtherCIGNA
NC2276981OtherAETNA
NC2276981OtherAETNA
205445Medicare ID - Type Unspecified