Provider Demographics
NPI:1093802365
Name:CLARK, KERRY R (MD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:R
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:23388 MULHOLLAND DR
Mailing Address - Street 2:MAILSTOP 62
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-2733
Mailing Address - Country:US
Mailing Address - Phone:818-876-1636
Mailing Address - Fax:661-290-3310
Practice Address - Street 1:25751 MCBEAN PKWY
Practice Address - Street 2:STE 210
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-3701
Practice Address - Country:US
Practice Address - Phone:661-284-3100
Practice Address - Fax:661-290-3310
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2009-06-24
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Provider Licenses
StateLicense IDTaxonomies
CAG60150207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G771370OtherBLUE SHIELD
CAWG60150IMedicare ID - Type Unspecified
E48096Medicare UPIN
CAWG60150JMedicare ID - Type Unspecified
CAWG60150LMedicare ID - Type Unspecified
CAWG60150KMedicare ID - Type Unspecified
CA00G771370OtherBLUE SHIELD