Provider Demographics
NPI:1962473397
Name:CLARK, DEBRA (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:
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 1:1409 RT 9
Mailing Address - Street 2:
Mailing Address - City:KEESEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12944-2845
Mailing Address - Country:US
Mailing Address - Phone:518-834-7271
Mailing Address - Fax:518-834-7086
Practice Address - Street 1:1409 RT 9
Practice Address - Street 2:
Practice Address - City:KEESEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12944-2845
Practice Address - Country:US
Practice Address - Phone:518-834-7271
Practice Address - Fax:518-834-7086
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1750471207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01604324Medicaid
NYE15687Medicare UPIN
NY51506BMedicare PIN