Provider Demographics
NPI:1255479424
Name:CLARK, STEVE EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVE
Middle Name:EDWARD
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 1:1885 MAIN ST STE 405
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1828
Mailing Address - Country:US
Mailing Address - Phone:808-242-8526
Mailing Address - Fax:
Practice Address - Street 1:1885 MAIN ST STE 405
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1828
Practice Address - Country:US
Practice Address - Phone:808-242-8526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD5400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIG55263Medicare UPIN