Provider Demographics
NPI:1073554242
Name:CLARK, RICHARD WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WAYNE
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 1:1245 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4806
Mailing Address - Country:US
Mailing Address - Phone:213-977-1215
Mailing Address - Fax:213-977-0404
Practice Address - Street 1:1245 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4810
Practice Address - Country:US
Practice Address - Phone:213-977-1215
Practice Address - Fax:213-977-0404
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23111207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0071560Medicaid
CAA41858Medicare UPIN
CAGR0071560Medicaid