Provider Demographics
NPI:1366424798
Name:CLARK, KATHERINE A (DO)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4172 INDIAN RIPPLE RD STE A
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45440-3286
Mailing Address - Country:US
Mailing Address - Phone:937-431-3779
Mailing Address - Fax:937-431-3776
Practice Address - Street 1:4172 INDIAN RIPPLE RD STE A
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45440-3286
Practice Address - Country:US
Practice Address - Phone:937-431-3779
Practice Address - Fax:937-431-3776
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004845207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0935368Medicaid
OH0935368Medicaid
OHH047800Medicare PIN
OHCL0783172Medicare PIN