Healthcare Provider Details

I. General information

NPI: 1750776290
Provider Name (Legal Business Name): CAITLIN CLARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST
TUPELO MS
38801-4996
US

IV. Provider business mailing address

4631 CEDAR GARDEN LN
BELDEN MS
38826-8201
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-3275
  • Fax:
Mailing address:
  • Phone: 901-484-8808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number29220
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: