Provider Demographics
NPI:1194791178
Name:CLARK, MA.BELEN S (MD)
Entity type:Individual
Prefix:DR
First Name:MA.BELEN
Middle Name:S
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 1:1954 VIA CTR STE B
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-6056
Mailing Address - Country:US
Mailing Address - Phone:760-529-9700
Mailing Address - Fax:
Practice Address - Street 1:1954 VIA CTR STE B
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-6056
Practice Address - Country:US
Practice Address - Phone:760-529-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-104581207P00000X
MO2004025497207Q00000X
CAA100202207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209071109Medicaid
EG9762OtherMEDICARE PTAN
ILH49397Medicare UPIN
ILK22023Medicare PIN
CA0A1002020Medicare PIN
MO209071109Medicaid
MO926632931Medicare ID - Type Unspecified