Provider Demographics
NPI:1457811515
Name:CLARK, KRISTA NOEL (DO)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:NOEL
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10496 MONTGOMERY RD STE 110
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5220
Mailing Address - Country:US
Mailing Address - Phone:513-671-7700
Mailing Address - Fax:513-671-5435
Practice Address - Street 1:10496 MONTGOMERY RD STE 110
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-5220
Practice Address - Country:US
Practice Address - Phone:513-671-7700
Practice Address - Fax:513-671-5435
Is Sole Proprietor?:No
Enumeration Date:2019-03-23
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.016635207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program