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General NPI Number Information
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NPI Number | 1699789263
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Entity Type | Individual
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Provider Name | TERALYNN S CLARK MD
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Gender | Female
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Dates
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Enumeration Date | 07/28/2006
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Last Update Date | 02/22/2013
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Provider Practice Location Address
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Address Line | 1201 MICKELSON DR STE 2
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City | WATERTOWN
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State | SD
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Zip | 57201-7253
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Country | US
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Telephone | 605-882-0432
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Fax | 605-882-0978
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Provider Business Mailing Address
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Address Line | 1201 MICKELSON DR STE 2
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City | WATERTOWN
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State | SD
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Zip | 57201-7253
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Country | US
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Telephone | 605-882-0432
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Fax | 605-882-0978
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 4316
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License Number State | SD
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