Provider Demographics
NPI:1457389892
Name:CLARK, JEANNINE AVIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANNINE
Middle Name:AVIS
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6915 LAUREL BOWIE ROAD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715
Mailing Address - Country:US
Mailing Address - Phone:301-249-8838
Mailing Address - Fax:301-249-5334
Practice Address - Street 1:6915 LAUREL BOWIE ROAD
Practice Address - Street 2:SUITE 301
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715
Practice Address - Country:US
Practice Address - Phone:301-249-8838
Practice Address - Fax:301-249-5334
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2023-06-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD0043862208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC62840Medicare UPIN