Provider Demographics
NPI:1134122948
Name:CLARK, STEPHEN E (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:E
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 1:28370 KENSINGTON LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-4163
Mailing Address - Country:US
Mailing Address - Phone:419-874-3125
Mailing Address - Fax:419-874-8606
Practice Address - Street 1:28370 KENSINGTON LN
Practice Address - Street 2:SUITE A
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-4163
Practice Address - Country:US
Practice Address - Phone:419-874-3125
Practice Address - Fax:419-874-8606
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063695207W00000X
IN01041459A207W00000X
MI4301069901207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH02272OtherPARAMOUNT HEALTH CARE
OH000000281826OtherANTHEM BLUE CROSS/SHIELD
OH5814164OtherAETNA
OH0292679Medicaid
OHP00010973Medicare PIN
OH02272OtherPARAMOUNT HEALTH CARE
OHF36988Medicare UPIN