Provider Demographics
NPI:1205078664
Name:CLARK, TODD V (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:V
Last Name:CLARK
Suffix:
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 1:250 FOUNTAIN CT
Mailing Address - Street 2:ATTN: LAUREN BRYANT
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1888
Mailing Address - Country:US
Mailing Address - Phone:859-263-4444
Mailing Address - Fax:859-254-1814
Practice Address - Street 1:250 FOUNTAIN CT
Practice Address - Street 2:ATTN: LAUREN BRYANT
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1888
Practice Address - Country:US
Practice Address - Phone:859-263-4444
Practice Address - Fax:859-254-1814
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42806207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000612211OtherANTHEM BLUE CROSS & BLUE SHIELD
000000612211OtherANTHEM BLUE CROSS & BLUE SHIELD
KY1270418Medicare PIN