Provider Demographics
NPI:1952410987
Name:CLARK-PAUL, KIMBERLEY CAROL (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:CAROL
Last Name:CLARK-PAUL
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 1:1216 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3555
Mailing Address - Country:US
Mailing Address - Phone:810-982-1111
Mailing Address - Fax:810-982-8848
Practice Address - Street 1:1221 RICHARDSON ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3548
Practice Address - Country:US
Practice Address - Phone:810-982-1111
Practice Address - Fax:810-982-8848
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301404907208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1952410987Medicaid
MIG46040151Medicare PIN
MI1952410987Medicaid