Provider Demographics
NPI:1225066939
Name:CLARK, RODERICK V (MD)
Entity Type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:V
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 1:2804 AMBASSADOR CAFFERY PKWY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-5906
Mailing Address - Country:US
Mailing Address - Phone:337-981-5156
Mailing Address - Fax:337-981-0673
Practice Address - Street 1:2804 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-5906
Practice Address - Country:US
Practice Address - Phone:337-981-5156
Practice Address - Fax:337-981-0673
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019518207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1379875Medicaid
LA55023Medicare ID - Type Unspecified
LA1379875Medicaid