Provider Demographics
NPI:1134109507
Name:CLARK, DANIELLE K (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:K
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1189
Mailing Address - Country:US
Mailing Address - Phone:641-621-2200
Mailing Address - Fax:641-621-2335
Practice Address - Street 1:405 MONROE ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1189
Practice Address - Country:US
Practice Address - Phone:641-621-2200
Practice Address - Fax:641-621-2335
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3371207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1556142Medicaid
IAP00059642OtherRAILROAD MEDICARE
IAH55963Medicare UPIN
IA1556142Medicaid
IAI10144Medicare PIN