Individual
VIVIAN M CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1503 W ELK AVE, SUITE 5, ELIZABETHTON, TN 37643-2876
(423) 542-0400
(423) 542-3265
Mailing address
1503 W ELK AVE, SUITE 5, ELIZABETHTON, TN 37643-2876
(423) 542-0400
(423) 542-3265
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
39360
TN
207R00000X
Internal Medicine Physician
MD39360
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3326510
—
TN
01
—
4146001
BCBS OF TENNESSEE
TN
01
—
TN0109
JOHN DEEREUHC
TN
Enumeration date
05/18/2006
Last updated
03/17/2018
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