Basic Information
| Provider Information | |||||||||
| NPI: | 1457495830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | KUDIRATU | ||||||||
| MiddleName: | ARANMOLATE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ARANMOLATE | ||||||||
| OtherFirstName: | KUDIRATU | ||||||||
| OtherMiddleName: | ATINUKE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2730 UNIVERSITY BOULEVARD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | WHEATON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209021979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019428799 | ||||||||
| FaxNumber: | 3019338554 | ||||||||
| Practice Location | |||||||||
| Address1: | 2730 UNIVERSITY BOULEVARD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | WHEATON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209021979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019428799 | ||||||||
| FaxNumber: | 3019338554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2007 | ||||||||
| LastUpdateDate: | 09/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | D0070652 | MD | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 69565 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.