Provider Demographics
NPI:1295711554
Name:LARK, REBECCA L (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:LARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601888
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1888
Mailing Address - Country:US
Mailing Address - Phone:704-331-9669
Mailing Address - Fax:704-331-0736
Practice Address - Street 1:4539 HEDGEMORE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3276
Practice Address - Country:US
Practice Address - Phone:704-331-9669
Practice Address - Fax:704-331-0736
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2000-00506207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN00507Medicaid
NC1295711554Medicaid
NC89126YRMedicaid
NCNCI847AMedicare PIN
NC1295711554Medicaid
NC2280303Medicare PIN