Provider Demographics
NPI:1851099683
Name:CLARK, DEMETRIUS
Entity type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
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 1:4462 CHARLOTTE RD
Mailing Address - Street 2:
Mailing Address - City:OBETZ
Mailing Address - State:OH
Mailing Address - Zip Code:43207-5232
Mailing Address - Country:US
Mailing Address - Phone:614-620-2758
Mailing Address - Fax:
Practice Address - Street 1:4462 CHARLOTTE RD
Practice Address - Street 2:
Practice Address - City:OBETZ
Practice Address - State:OH
Practice Address - Zip Code:43207-5232
Practice Address - Country:US
Practice Address - Phone:614-620-2758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health