1518731298 NPI number — TIMOTHY JOHN CLARK PT, DPT

Table of content: TIMOTHY JOHN CLARK PT, DPT (NPI 1518731298)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518731298 NPI number — TIMOTHY JOHN CLARK PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
TIMOTHY
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
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:
1518731298
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1650 LYNDON FARM CT STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40223-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-677-4000
Provider Business Mailing Address Fax Number:
856-234-3014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1341F FAIRVIEW BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELRAN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-461-9393
Provider Business Practice Location Address Fax Number:
856-824-1407
Provider Enumeration Date:
11/13/2023

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: 225100000X , with the licence number:  PT013766L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 40QA00898300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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