1265562185 NPI number — DUSTIN E CLARK

Table of content: DUSTIN E CLARK (NPI 1265562185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265562185 NPI number — DUSTIN E CLARK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
DUSTIN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265562185
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1013
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALDEZ
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99686
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-200-4995
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 SCENEGA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALDEZ
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-835-3274
Provider Business Practice Location Address Fax Number:
907-835-3512
Provider Enumeration Date:
03/07/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 172A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 372500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 372600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 373H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3747A0650X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3747P1801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 374U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)