Basic Information
| Provider Information | |||||||||
| NPI: | 1881676286 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5800 FOXRIDGE DR | ||||||||
| Address2: | STE 240 | ||||||||
| City: | MISSION | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662022347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132613153 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20333 W 151ST ST | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660615350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137914291 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2005 | ||||||||
| LastUpdateDate: | 11/22/2016 | ||||||||
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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 | 2085R0202X | 04-26770 | KS | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | 0426770 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0204X | 0426770 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0203X | 0426770 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085P0229X | 0426770 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085N0904X | 0426770 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085N0700X | 0426770 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085B0100X | 0426770 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
ID Information
| ID | Type | State | Issuer | Description | 100331230D | 05 | KS | MEDICAID |