1811952385 NPI number — DAVID B CLARK MD

Table of content: DAVID B CLARK MD (NPI 1811952385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811952385 NPI number — DAVID B CLARK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
DAVID
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1811952385
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9051 WATSON RD
Provider Second Line Business Mailing Address:
#263
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63126-2240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-667-5397
Provider Business Mailing Address Fax Number:
314-627-0767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9051 WATSON RD
Provider Second Line Business Practice Location Address:
#263
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63126-2240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-667-5397
Provider Business Practice Location Address Fax Number:
314-627-0767
Provider Enumeration Date:
04/19/2006

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: 208D00000X , with the licence number:  2003015259 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207L00000X , with the licence number: 2003015259 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2002364 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 145402 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 127254 . This is a "BLUE CHOICE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 127254 . This is a "BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 208429605 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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