MEDICARE: DR. SANDRA MARSHALL CLARK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	15683	AZ

General Provider Information

NPI Number	:	1578666046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANDRA MARSHALL CLARK M.D.

Provider Business Mailing Address
First Line	:	1002 W SAN MARTIN DR
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85704-3143
Country	:	US
Telephone Number	:	520-742-0716
Fax Number	:	520-575-8368

Provider Business Practice Location Address
First Line	:	1002 W SAN MARTIN DR
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85704-3143
Country	:	US
Telephone Number	:	520-742-0716
Fax Number	:	520-575-8368

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2006
Last Update Date	:	07/08/2007

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