Provider Demographics
NPI:1528689254
Name:CLARK, VINCENT DEVIN
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:DEVIN
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 MARKET ST STE A
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-7986
Mailing Address - Country:US
Mailing Address - Phone:502-225-6900
Mailing Address - Fax:502-666-7693
Practice Address - Street 1:1230 MARKET ST STE A
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-7986
Practice Address - Country:US
Practice Address - Phone:502-225-6900
Practice Address - Fax:502-666-7693
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY61113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine