Provider Demographics
NPI:1285661306
Name:CLARK, SHAWN GERALD (DO)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:GERALD
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 EAST MOUNTAIN DRIVE, GEISINGER MEDICAL CENTER
Mailing Address - Street 2:MC 34-20
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18711
Mailing Address - Country:US
Mailing Address - Phone:570-808-7818
Mailing Address - Fax:
Practice Address - Street 1:1000 EAST MOUNTAIN DRIVE, GEISINGER MEDICAL CENTER
Practice Address - Street 2:MC 34-20
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711
Practice Address - Country:US
Practice Address - Phone:570-808-7818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012489207P00000X
WVWV 2166207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101386321Medicaid
I43749Medicare UPIN
PA101386321Medicaid