Provider Demographics
NPI:1962727743
Name:CLARK, KRISTA M (DO)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:M
Other - Last Name:BLACKMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2791 N WASHINGTON ST
Mailing Address - Street 2:HEDRICK FAMILY CARE
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601-2902
Mailing Address - Country:US
Mailing Address - Phone:660-646-2682
Mailing Address - Fax:660-214-8611
Practice Address - Street 1:2791 N WASHINGTON ST
Practice Address - Street 2:HEDRICK FAMILY CARE
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-2902
Practice Address - Country:US
Practice Address - Phone:660-646-2682
Practice Address - Fax:660-214-8611
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-05
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013021426207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine