Provider Demographics
NPI:1235166943
Name:CLARK, JOHN D (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1130 W 4TH ST STE 3203
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-1328
Mailing Address - Country:US
Mailing Address - Phone:785-830-8324
Mailing Address - Fax:785-505-5260
Practice Address - Street 1:1130 W 4TH ST STE 3203
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1328
Practice Address - Country:US
Practice Address - Phone:785-830-8324
Practice Address - Fax:785-505-5260
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-238642084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200300630AMedicaid
KSG04308Medicare UPIN
KS103764Medicare ID - Type Unspecified