Provider Demographics
NPI:1073938973
Name:CLARK, SHAWN (DO)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2094 E STATE ST STE A
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-4409
Mailing Address - Country:US
Mailing Address - Phone:330-337-2868
Mailing Address - Fax:330-337-2875
Practice Address - Street 1:2094 E STATE ST STE A
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-4409
Practice Address - Country:US
Practice Address - Phone:330-337-2868
Practice Address - Fax:330-337-2875
Is Sole Proprietor?:No
Enumeration Date:2014-02-28
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0000000000000207R00000X
OH34-012867208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine