Basic Information
| Provider Information | |||||||||
| NPI: | 1265433940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 411039 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641411039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132341350 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12300 METCALF AVE | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662131324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133177485 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 07/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 04-27540 | KS | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 208678029 | 05 | MO | MEDICAID | 100317940C | 05 | KS | MEDICAID | 25062077 | 01 | MO | BCBS KC MO | OTHER | 01674018 | 01 | KS | BCBS OF KC MO GROUP ID # | OTHER | 25062057 | 01 | MO | BCBS OF KC MO | OTHER | 930066218 | 01 | RR MEDICARE GROUP CG8899 | OTHER | P00188856 | 01 | RR MEDICARE GROUP DC6712 | OTHER | 100317940A | 05 | KS | MEDICAID |