Provider Demographics
NPI:1336249341
Name:CLARK, BARRY A (MD)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:A
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 1:1B MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1601
Mailing Address - Country:US
Mailing Address - Phone:570-724-7100
Mailing Address - Fax:570-724-1501
Practice Address - Street 1:1B MAIN ST
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1601
Practice Address - Country:US
Practice Address - Phone:570-724-7100
Practice Address - Fax:570-724-1501
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029130E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
0065299000OtherPERSONAL CHOICE
NY01032526Medicaid
13037OtherGHP
PA0009089200001Medicaid
304219OtherUPHC
4623938OtherAETNA
002502OtherFIRST PRIORITY
2603062OtherGHI
PA0606293OtherACCESS CARE II
PA39D0980728OtherCLEA
794397OtherHEALTH CARE ADVANTAGE
CX28OtherHEALTH ASSURANCE
PA070598OtherBLUE SHIELD
PA0606293OtherACCESS CARE II