Provider Demographics
NPI:1952571143
Name:CLARK, TAMETA ROSETTE (MD)
Entity type:Individual
Prefix:DR
First Name:TAMETA
Middle Name:ROSETTE
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 1:6307 GATEWAY CIR
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-5540
Mailing Address - Country:US
Mailing Address - Phone:919-225-7085
Mailing Address - Fax:
Practice Address - Street 1:220 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-3709
Practice Address - Country:US
Practice Address - Phone:224-278-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-04
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD24504207LP2900X
MDD0075864208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD292889ZAZQMedicare PIN