1780666594 NPI number — DR. CRAIG B CLARK D.O.

Table of content: DR. CRAIG B CLARK D.O. (NPI 1780666594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780666594 NPI number — DR. CRAIG B CLARK D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
CRAIG
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1780666594
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 PENN AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50316-2350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-263-2400
Provider Business Mailing Address Fax Number:
515-263-2540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 PENN AVENUE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50316-2364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-263-2400
Provider Business Practice Location Address Fax Number:
515-263-2540
Provider Enumeration Date:
11/17/2005

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: 207RC0000X , with the licence number:  03037 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1780666594 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1240796 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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