Provider Demographics
NPI:1972502938
Name:CLARKE, KATHY L (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:L
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHY
Other - Middle Name:M
Other - Last Name:SADR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5261 CARROLLTON PIKE
Mailing Address - Street 2:SUITE B
Mailing Address - City:WOODLAWN
Mailing Address - State:VA
Mailing Address - Zip Code:24381-3030
Mailing Address - Country:US
Mailing Address - Phone:276-238-8876
Mailing Address - Fax:276-238-8886
Practice Address - Street 1:5261 CARROLLTON PIKE
Practice Address - Street 2:SUITE B
Practice Address - City:WOODLAWN
Practice Address - State:VA
Practice Address - Zip Code:24381-3030
Practice Address - Country:US
Practice Address - Phone:276-238-8876
Practice Address - Fax:276-238-8886
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101102706207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DN2980OtherGROUP PTAN
VA0101102706OtherLC
C10361OtherGROUP ORGANIZATION PTAN
261083931OtherTAX ID
VA1972502938Medicaid
VA1972502938Medicaid
VAFC1573600OtherDEA