Provider Demographics
NPI:1558473884
Name:CLARK, KRISTIE M (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTIE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:715 SOUTHWIND DR
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66441-9021
Mailing Address - Country:US
Mailing Address - Phone:785-209-3779
Mailing Address - Fax:785-209-3780
Practice Address - Street 1:715 SOUTHWIND DR
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441-9021
Practice Address - Country:US
Practice Address - Phone:785-209-3779
Practice Address - Fax:785-209-3780
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-34215208000000X
TXL6831208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004570650001Medicaid
TX137227810Medicaid
H92561Medicare UPIN
TXH92561Medicare UPIN
458811Medicare Oscar/Certification