Provider Demographics
NPI:1548495336
Name:CLARK, SHANE CHAMBERLAIN (MD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:CHAMBERLAIN
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 1:347 W MILLTOWN RD STE B
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-7216
Mailing Address - Country:US
Mailing Address - Phone:330-345-1540
Mailing Address - Fax:330-345-1541
Practice Address - Street 1:347 W MILLTOWN RD STE B
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-7216
Practice Address - Country:US
Practice Address - Phone:330-345-1540
Practice Address - Fax:330-345-1541
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35121081207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000814530OtherANTHEM BC/BS
OH9095975OtherAETNA
OH4098919OtherCIGNA
OH000000814530OtherANTHEM BC/BS