Provider Demographics
NPI:1982752994
Name:CLARK, MARK E (MS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 950116
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0116
Mailing Address - Country:US
Mailing Address - Phone:502-893-0159
Mailing Address - Fax:502-213-3853
Practice Address - Street 1:4004 DUPONT CIR
Practice Address - Street 2:STE 220
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4819
Practice Address - Country:US
Practice Address - Phone:502-893-0159
Practice Address - Fax:502-213-3853
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0124015Medicare PIN
KY0098619Medicare PIN