Healthcare Provider Details

I. General information

NPI: 1457098154
Provider Name (Legal Business Name): CLARK KELLOGG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

799 LEXINGTON AVE
MANSFIELD OH
44907-1906
US

IV. Provider business mailing address

5910 BLUESTONE WAY
LEWIS CENTER OH
43035-7550
US

V. Phone/Fax

Practice location:
  • Phone: 419-756-5133
  • Fax: 419-774-9707
Mailing address:
  • Phone: 614-301-2639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number32698321
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: