Provider Demographics
NPI:1467451807
Name:CLARK, TERRY D (MD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:D
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 1:290 BIG RUN RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2903
Mailing Address - Country:US
Mailing Address - Phone:859-278-9513
Mailing Address - Fax:859-277-6063
Practice Address - Street 1:290 BIG RUN RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2903
Practice Address - Country:US
Practice Address - Phone:859-278-9513
Practice Address - Fax:859-277-6063
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21388207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64213887Medicaid
KYC66046Medicare UPIN
KY0058110Medicare PIN
KY0085111Medicare PIN
KY0084009Medicare PIN