Provider Demographics
NPI:1215257217
Name:CLARK, CHRISTOPHER DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:DAVID
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13114 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-3720
Mailing Address - Country:US
Mailing Address - Phone:301-800-7770
Mailing Address - Fax:301-800-7891
Practice Address - Street 1:13114 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2741
Practice Address - Country:US
Practice Address - Phone:301-800-7770
Practice Address - Fax:301-800-7891
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09515800208100000X
PAMD451865208100000X
MDD0082490208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0460583Medicaid
MD9822046Medicaid