Provider Demographics
NPI:1023042470
Name:CLARK, RICHARD R (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:R
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 E BELVIDERE RD UNIT 385
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2026
Mailing Address - Country:US
Mailing Address - Phone:847-535-8000
Mailing Address - Fax:
Practice Address - Street 1:1475 E BELVIDERE RD UNIT 385
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2026
Practice Address - Country:US
Practice Address - Phone:847-535-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38607207Q00000X
IL003-036-082187-01207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E84263Medicare UPIN