Provider Demographics
NPI:1811066319
Name:CLARK, SUSAN H (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:H
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 ASH ST
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:IL
Mailing Address - Zip Code:60093-2102
Mailing Address - Country:US
Mailing Address - Phone:312-952-3392
Mailing Address - Fax:847-501-3857
Practice Address - Street 1:1004 ASH ST
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:IL
Practice Address - Zip Code:60093-2102
Practice Address - Country:US
Practice Address - Phone:312-952-3392
Practice Address - Fax:847-501-3857
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061182084P0800X
IL0360601182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
537220OtherPIN
D14723Medicare UPIN
67705026Medicare ID - Type Unspecified