Provider Demographics
NPI:1386158525
Name:CLARK, M. JUSTINE (DO)
Entity type:Individual
Prefix:
First Name:M.
Middle Name:JUSTINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 RIDGELY AVE STE 214
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-8804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 RIDGELY AVE STE 214
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-8804
Practice Address - Country:US
Practice Address - Phone:410-573-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0041992208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice