Healthcare Provider Details

I. General information

NPI: 1497155220
Provider Name (Legal Business Name): CAROLYN MAE CLARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5721 W 119TH ST
OVERLAND PARK KS
66209-3753
US

IV. Provider business mailing address

5721 W 119TH ST
OVERLAND PARK KS
66209-3753
US

V. Phone/Fax

Practice location:
  • Phone: 913-498-6000
  • Fax:
Mailing address:
  • Phone: 913-498-6623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number04-42111
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: