Provider Demographics
NPI:1386879062
Name:CLARK, KIMBERLY (MD/PHD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 KILBERRY DR
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-9736
Mailing Address - Country:US
Mailing Address - Phone:404-824-1518
Mailing Address - Fax:
Practice Address - Street 1:1364 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1059
Practice Address - Country:US
Practice Address - Phone:616-308-8618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-24
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-00534207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine