Provider Demographics
NPI:1073504767
Name:CLARK, TODD (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1143
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:1775 W DEMPSTER ST
Practice Address - Street 2:1 WEST
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1143
Practice Address - Country:US
Practice Address - Phone:847-723-5150
Practice Address - Fax:847-723-2083
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84896207P00000X, 207PE0004X
IL036-107180207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A84896Medicaid
CA00A848960Medicaid
CAWA84896CMedicare PIN
CA00A848960Medicaid
CAHA84896Medicare PIN
CAH83604Medicare UPIN