Basic Information
| Provider Information | |||||||||
| NPI: | 1518936871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 201868 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995201868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077702380 | ||||||||
| FaxNumber: | 9077702341 | ||||||||
| Practice Location | |||||||||
| Address1: | 3220 PROVIDENCE DR | ||||||||
| Address2: | STE E3040 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077703750 | ||||||||
| FaxNumber: | 9077703795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 08/26/2010 | ||||||||
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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 | 207RP1001X | 3182 | AK | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | MD3182 | 05 | AK | MEDICAID | 290009977 | 01 | RAILROAD | OTHER |