Basic Information
| Provider Information | |||||||||
| NPI: | 1831268531 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2024 GEORGIA AVE NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200013027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025953223 | ||||||||
| FaxNumber: | 2023322985 | ||||||||
| Practice Location | |||||||||
| Address1: | 2041 GEORGIA AVE NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200600001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028656711 | ||||||||
| FaxNumber: | 2028656713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 08/03/2007 | ||||||||
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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 | 207L00000X | MD30288 | DC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 005719933 | 05 | VA | MEDICAID | 026516400 | 05 | DC | MEDICAID | 914510900 | 05 | MD | MEDICAID |