Provider Demographics
NPI:1801976105
Name:CLARK, CHRISTOPHER TIMOTHY (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:TIMOTHY
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 1:20575 ERIE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-1414
Mailing Address - Country:US
Mailing Address - Phone:216-476-7108
Mailing Address - Fax:216-476-7109
Practice Address - Street 1:1924 ALCOA HWY
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1511
Practice Address - Country:US
Practice Address - Phone:865-305-8994
Practice Address - Fax:865-305-6866
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.072415207ZP0102X
WI38281-020207ZP0102X
TN44055207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSY245065068OtherTRICARE
OH000000180176OtherOHIO OPERATING ENGINEERS
OH2042373Medicaid
OH2042373OtherBCMH
OH340714618011OtherMEDICAL MUTUAL OF OHIO
TN4203908OtherBCBS OF TN
OH000000180176OtherANTHEM BC/BS
TN1510737Medicaid
TNP00747161OtherRR MEDICARE PART B
WVCL7260091Medicare ID - Type UnspecifiedOHIO/WEST VIRGINIA
OH220026042Medicare ID - Type UnspecifiedRR MEDICARE PART B
OHSY245065068OtherTRICARE
OH2042373Medicaid