Provider Demographics
NPI:1699789263
Name:CLARK, TERALYNN S (MD)
Entity type:Individual
Prefix:
First Name:TERALYNN
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1201 MICKELSON DR STE 2
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-7253
Mailing Address - Country:US
Mailing Address - Phone:605-882-0432
Mailing Address - Fax:605-882-0978
Practice Address - Street 1:1201 MICKELSON DR STE 2
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-7253
Practice Address - Country:US
Practice Address - Phone:605-882-0432
Practice Address - Fax:605-882-0978
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2013-02-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SD4316207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0007400OtherBCBS
MN235822100Medicaid
SD5707122Medicaid
MN59F05CLOtherBCBS
SD5707122Medicaid
MN235822100Medicaid
MN59F05CLOtherBCBS