MEDICARE: DR. DOROTHY CLARK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	20762	KY

General Provider Information

NPI Number	:	1720083959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOROTHY CLARK M.D.

Provider Business Mailing Address
First Line	:	1707 NICHOLASVILLE RD
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40503-1403
Country	:	US
Telephone Number	:	859-276-5577
Fax Number	:	859-277-4048

Provider Business Practice Location Address
First Line	:	1707 NICHOLASVILLE RD
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40503-1403
Country	:	US
Telephone Number	:	859-276-5577
Fax Number	:	859-277-4048

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	07/08/2007

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