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NPI Code Detail

MEDICARE: CAITLIN CLARK M.D.

MEDICARE: CAITLIN 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
1208M00000XHospitalist Physician29220MS
2390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1750776290
Entity Type Code : Individual
Provider Name (Legal Business Name) : CAITLIN CLARK M.D.
Provider Business Mailing Address
First Line : 4631 CEDAR GARDEN LN
Second Line :
City : BELDEN
State : MS
Zip : 38826-8201
Country : US
Telephone Number : 901-484-8808
Fax Number :
Provider Business Practice Location Address
First Line : 830 S GLOSTER ST
Second Line :
City : TUPELO
State : MS
Zip : 38801-4996
Country : US
Telephone Number : 662-377-3275
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/01/2015
Last Update Date : 09/26/2022

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