Provider Demographics
NPI:1235181132
Name:CLARK, DOUGLAS PAUL (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:PAUL
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 1:1 UNIVERSITY OF NEW MEXICO PATHOLOGY MSC08
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-4814
Mailing Address - Fax:505-272-8084
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:DEPATMENT OF PATHOLOGY
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:505-272-4814
Practice Address - Fax:505-272-8084
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2013-0937207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD231351100Medicaid
MD231351100Medicaid
MDKR36158LMedicare ID - Type Unspecified