Healthcare Provider Details

I. General information

NPI: 1962449017
Provider Name (Legal Business Name): CURTIS R CLARK II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WHEELING AVE
GLEN DALE WV
26038-3357
US

IV. Provider business mailing address

299 TOWNSHIP ROAD 1214
IRONTON OH
45638-8809
US

V. Phone/Fax

Practice location:
  • Phone: 304-843-3270
  • Fax:
Mailing address:
  • Phone: 304-673-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35087466
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number21517
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: