Provider Demographics
NPI:1780697334
Name:CLARK, SUSANNAH TAYLOR (MD)
Entity type:Individual
Prefix:DR
First Name:SUSANNAH
Middle Name:TAYLOR
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSANNAH
Other - Middle Name:CORD
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:DHMC - DEPARTMENT OF GENERAL INTERNAL MEDICINE
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:603-650-5000
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:DHMC DEPARTMENT OF GENERAL INTERNAL MEDICINE
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-650-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30205694Medicaid
VT1011886Medicaid
NH30205694Medicaid
VT1011886Medicaid