Provider Demographics
NPI:1083773931
Name:CLARK, DONALD WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
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 1:801 VASSAR NE
Mailing Address - Street 2:ALBUQUERQUE INDIAN HEALTH CLINIC
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106
Mailing Address - Country:US
Mailing Address - Phone:505-248-4065
Mailing Address - Fax:505-248-4093
Practice Address - Street 1:801 VASSAR NE
Practice Address - Street 2:ALBUQUERQUE INDIAN HEALTH CENTER
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-248-4065
Practice Address - Fax:505-248-4093
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM96216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
13026OtherPRESBYTERIAN HEALTH PLAN
NMHSZ162OtherMEDICARE GROUP PTAN
NMS5748Medicaid
NM05679079Medicaid
AZ723553Medicaid
2618OtherLOVELACE SALUD
NM8HZ91WOtherMEDICARE PTAN
NMHSZ196OtherMEDICARE PART B
NMK3526Medicaid
NM8HZ91WOtherMEDICARE PTAN
NMHSZ196OtherMEDICARE PART B
D79850Medicare UPIN