Individual
DR. KENNETH A CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
199 HOSPITAL DR, SUITE 5, GALAX, VA 24333-2454
(276) 236-6136
Mailing address
199 HOSPITAL DR, SUITE 5, GALAX, VA 24333-2454
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
0101-041662
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
005826772
—
VA
05
—
005826781
—
VA
05
—
010022100
—
VA
05
—
010044065
—
VA
Enumeration date
11/30/2005
Last updated
10/24/2014
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