Basic Information
| Provider Information | |||||||||
| NPI: | 1952582397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CLARENCE | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 33269 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850673269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024064786 | ||||||||
| FaxNumber: | 9166364358 | ||||||||
| Practice Location | |||||||||
| Address1: | 1955 W FRYE RD | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852246282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807283000 | ||||||||
| FaxNumber: | 4807284747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2007 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 068132 | GA | N | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | N2443 | TX | N | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208C00000X | 61606 | AZ | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 003126879C | 05 | GA | MEDICAID | 003126879A | 05 | GA | MEDICAID |