Provider Demographics
NPI:1104096650
Name:CLARK, SUSAN CHRISTINE (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:CHRISTINE
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:NAVAL MEDICAL CENTER PORTSMOUTH
Mailing Address - Street 2:620 JOHN PAUL JONES CIRCLE
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23708-9971
Mailing Address - Country:US
Mailing Address - Phone:757-953-9759
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MEDICAL CENTER PORTSMOUTH
Practice Address - Street 2:620 JOHN PAUL JONES CIRCLE
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708
Practice Address - Country:US
Practice Address - Phone:757-953-9759
Practice Address - Fax:757-953-0845
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-00718208600000X
PAMD426779208600000X
VA0101253279208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5918139Medicaid
NC163WHOtherBCBSNC
NCNC0553AMedicare PIN