Provider Demographics
NPI:1962470823
Name:CLARK, ERIN LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:LOUISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:LOUISE
Other - Last Name:BALDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2817 REILLY ROAD
Mailing Address - Street 2:WOMACK ARMY MEDICAL CENTER MCXC-COD CREDENTIALS
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310
Mailing Address - Country:US
Mailing Address - Phone:910-907-8922
Mailing Address - Fax:910-907-6069
Practice Address - Street 1:WOMACK ARMY MEDICAL CENTER
Practice Address - Street 2:DEPT OF MEDICINE
Practice Address - City:FT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310
Practice Address - Country:US
Practice Address - Phone:910-907-8690
Practice Address - Fax:910-907-8360
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN