1568566917 NPI number — DR. DERRICK J CLARK PHD

Table of content: DR. DERRICK J CLARK PHD (NPI 1568566917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568566917 NPI number — DR. DERRICK J CLARK PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
DERRICK
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1568566917
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:
1663 DOMINICAN WAY
Provider Second Line Business Mailing Address:
STE 214
Provider Business Mailing Address City Name:
SANTA CRUZ
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95065-1527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-475-3231
Provider Business Mailing Address Fax Number:
831-462-4936

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1663 DOMINICAN WAY
Provider Second Line Business Practice Location Address:
STE 214
Provider Business Practice Location Address City Name:
SANTA CRUZ
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95065-1527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-475-3231
Provider Business Practice Location Address Fax Number:
831-462-4936
Provider Enumeration Date:
09/07/2006

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: 103T00000X , with the licence number:  PSY13424 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PSY134241 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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