Basic Information
| Provider Information | |||||||||
| NPI: | 1942277652 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | VIVIAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 CONNER DRIVE | ||||||||
| Address2: | # 101 | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199428571 | ||||||||
| FaxNumber: | 9199426355 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 CONNER DR | ||||||||
| Address2: | #101 CHAPEL HILL OB GYN | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199428571 | ||||||||
| FaxNumber: | 9199426355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 09/22/2014 | ||||||||
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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 | 207V00000X | 30614 | NC | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 22171 | 01 | NC | BCBS | OTHER | 22179 | 01 | NC | MEDCOST | OTHER | 1284188003 | 01 | NC | UHC | OTHER | 154773 | 01 | NC | WELLPATH | OTHER | 7922717 | 05 | NC | MEDICAID | 562142486 | 01 | NC | BEECHSTREET | OTHER | 2855944 | 01 | NC | CIGNA | OTHER | 2276981 | 01 | NC | AETNA | OTHER |