Healthcare Provider Details

I. General information

NPI: 1447366976
Provider Name (Legal Business Name): KEVIN DAVID CLARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1099 OHIO RIVER BLVD CRITMORE PROFESSIONAL BUILDING
SEWICKLEY PA
15143-2056
US

IV. Provider business mailing address

1099 OHIO RIVER BLVD CRITMORE PROFESSIONAL BUILDING
SEWICKLEY PA
15143-2056
US

V. Phone/Fax

Practice location:
  • Phone: 412-741-6776
  • Fax: 412-741-1390
Mailing address:
  • Phone: 412-741-6776
  • Fax: 412-741-1390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD-049725-L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0014256600001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: