1467526509 NPI number — DR. CLARK W PILLSBURY DPM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467526509 NPI number — DR. CLARK W PILLSBURY DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PILLSBURY
Provider First Name:
CLARK
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1467526509
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10463 DOUBLE R BLVD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89521-8908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-358-2542
Provider Business Mailing Address Fax Number:
775-358-1413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10463 DOUBLE R BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89521-8908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-358-2542
Provider Business Practice Location Address Fax Number:
775-358-1413
Provider Enumeration Date:
11/20/2006

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: 213E00000X , with the licence number:  8801 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00036112 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 002116004 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com