Healthcare Provider Details

I. General information

NPI: 1295711554
Provider Name (Legal Business Name): REBECCA L. LARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4539 HEDGEMORE DR SUITE 100
CHARLOTTE NC
28209-3276
US

IV. Provider business mailing address

PO BOX 601888
CHARLOTTE NC
28260-1888
US

V. Phone/Fax

Practice location:
  • Phone: 704-331-9669
  • Fax: 704-331-0736
Mailing address:
  • Phone: 704-331-9669
  • Fax: 704-331-0736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number2000-00506
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: