Provider Demographics
NPI:1902880370
Name:CLARK, KENNETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 HOSPITAL DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:199 HOSPITAL DR
Practice Address - Street 2:SUITE 5
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2454
Practice Address - Country:US
Practice Address - Phone:276-236-6136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-041662207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005826772Medicaid
VA005826781Medicaid
VA010044065Medicaid
VA010022100Medicaid
110007468Medicare PIN
003350C86Medicare PIN
003349C40Medicare PIN
VA005826772Medicaid
VA010044065Medicaid
VA010022100Medicaid