Provider Demographics
NPI:1174608137
Name:CLARK, S KATHLEEN (MD)
Entity type:Individual
Prefix:
First Name:S
Middle Name:KATHLEEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37130-3935
Mailing Address - Country:US
Mailing Address - Phone:615-896-2617
Mailing Address - Fax:
Practice Address - Street 1:1132 DOW ST
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-2486
Practice Address - Country:US
Practice Address - Phone:615-896-2617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000015766207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0018534OtherTENNESSEE BLUE CROSS BLUE
TN3032646Medicaid
TN110025193OtherRAILROAD MEDICARE
TN3032646Medicaid
TN3032646Medicare PIN