Provider Demographics
NPI:1144229832
Name:CLARK, ERIC D (MD)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8244 E US HIGHWAY 36
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9575
Mailing Address - Country:US
Mailing Address - Phone:317-272-7500
Mailing Address - Fax:317-272-7515
Practice Address - Street 1:8244 E US HIGHWAY 36
Practice Address - Street 2:SUITE 1100
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9575
Practice Address - Country:US
Practice Address - Phone:317-272-7500
Practice Address - Fax:317-272-7515
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01022701207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INE03731Medicare UPIN
IN343800BMedicare ID - Type Unspecified