Provider Demographics
NPI:1568041655
Name:CLARK, DEREK BLAINE (DO)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:BLAINE
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-316-5800
Mailing Address - Fax:
Practice Address - Street 1:17385 LANKFORD HWY
Practice Address - Street 2:
Practice Address - City:PARKSLEY
Practice Address - State:VA
Practice Address - Zip Code:23421-3882
Practice Address - Country:US
Practice Address - Phone:757-665-5996
Practice Address - Fax:757-665-5973
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0102208196207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine