Healthcare Provider Details

I. General information

NPI: 1255321386
Provider Name (Legal Business Name): HEIDI MARIE CLARK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 TRIEBLE DR
TUNKHANNOCK PA
18657-7054
US

IV. Provider business mailing address

100 N ACADEMY AVE CREDENTIALS DEPT
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-996-2700
  • Fax: 570-996-2711
Mailing address:
  • Phone: 570-271-6144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS012488
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier1027140510001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: