1629144654 NPI number — KARL D CLARKSON DC

Table of content: KARL D CLARKSON DC (NPI 1629144654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629144654 NPI number — KARL D CLARKSON DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARKSON
Provider First Name:
KARL
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1629144654
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
403 HOWARD STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHINNSTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26431-1106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-592-3301
Provider Business Mailing Address Fax Number:
304-592-2130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
403 HOWARD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHINNSTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26431-1106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-592-3301
Provider Business Practice Location Address Fax Number:
304-592-2130
Provider Enumeration Date:
11/28/2006

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: 111N00000X , with the licence number:  WV407 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 407 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1024124 . This is a "WC" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 000080382 . This is a "MSBC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0132440000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5545040 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: WV00407 . This is a "HEALTH PLAN" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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