Provider Demographics
NPI:1003965419
Name:CLARK, ROY D JR (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:D
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:509 OLIVE WAY
Mailing Address - Street 2:#531
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1725
Mailing Address - Country:US
Mailing Address - Phone:206-682-5203
Mailing Address - Fax:206-682-5304
Practice Address - Street 1:509 OLIVE WAY
Practice Address - Street 2:#531
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1725
Practice Address - Country:US
Practice Address - Phone:206-682-5203
Practice Address - Fax:206-682-5304
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD000165162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
A04266Medicare UPIN
WA101126Medicare ID - Type Unspecified