Provider Demographics
NPI:1932177508
Name:CLARK, KRISTIN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5018 DORSEY HALL DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7855
Mailing Address - Country:US
Mailing Address - Phone:410-730-8288
Mailing Address - Fax:888-235-9533
Practice Address - Street 1:5018 DORSEY HALL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7855
Practice Address - Country:US
Practice Address - Phone:410-730-8288
Practice Address - Fax:888-235-9533
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0053966207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G94481Medicare UPIN