1821308974 NPI number — DR. DOUGLAS OWEN CLARK MD

Table of content: DR. DOUGLAS OWEN CLARK MD (NPI 1821308974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821308974 NPI number — DR. DOUGLAS OWEN CLARK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
DOUGLAS
Provider Middle Name:
OWEN
Provider Name Prefix Text:
DR.
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:
1821308974
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2418 E BLUEJAY BLUFF LN
Provider Second Line Business Mailing Address:
A
Provider Business Mailing Address City Name:
GREEN VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85614-5568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-791-6184
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21010 BLACK WALNUT LN
Provider Second Line Business Practice Location Address:
A
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53045-4062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-780-0594
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/07/2010

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: 207V00000X , with the licence number:  16533 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NONE . This is a "NONE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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