Basic Information
| Provider Information | |||||||||
| NPI: | 1295711554 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARK | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601888 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043319669 | ||||||||
| FaxNumber: | 7043310736 | ||||||||
| Practice Location | |||||||||
| Address1: | 4539 HEDGEMORE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043319669 | ||||||||
| FaxNumber: | 7043310736 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 08/18/2014 | ||||||||
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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 | 207RI0200X | 2000-00506 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | N00507 | 05 | SC | MEDICAID | 1295711554 | 05 | NC | MEDICAID | 89126YR | 05 | NC | MEDICAID |