Provider Demographics
NPI:1962449017
Name:CLARK, CURTIS R II (MD)
Entity Type:Individual
Prefix:
First Name:CURTIS
Middle Name:R
Last Name:CLARK
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 TOWNSHIP ROAD 1214
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-8809
Mailing Address - Country:US
Mailing Address - Phone:304-673-1020
Mailing Address - Fax:
Practice Address - Street 1:800 WHEELING AVE
Practice Address - Street 2:
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-3357
Practice Address - Country:US
Practice Address - Phone:304-843-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35087466207L00000X
WV21517207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2547944Medicaid
I12949Medicare UPIN
OHH146251Medicare PIN