Provider Demographics
NPI:1205889508
Name:CLARK, VIVIAN M (MD)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:L
Other - Last Name:MERCADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1503 W ELK AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2876
Mailing Address - Country:US
Mailing Address - Phone:423-542-0400
Mailing Address - Fax:423-542-3265
Practice Address - Street 1:1503 W ELK AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2876
Practice Address - Country:US
Practice Address - Phone:423-542-0400
Practice Address - Fax:423-542-3265
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD39360207R00000X
TN39360207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4146001OtherBCBS OF TENNESSEE
TNTN0109OtherJOHN DEEREUHC
TN3326510Medicaid
TN3326510Medicaid
TN3326510Medicare ID - Type Unspecified