Provider Demographics
NPI:1285664052
Name:CLARK, STEVEN M (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 E COUNTY LINE ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143
Practice Address - Country:US
Practice Address - Phone:317-865-8000
Practice Address - Fax:317-865-8012
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052195A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000091132OtherANTHEM BLUE CROSS
IN020047583OtherMEDICARE RAILROAD
10781002OtherCAQH ID
IN200281580AMedicaid
INP01456868OtherMEDICARE RR
IN000000014025OtherMDWISE/PROHEALTH
IN5263695OtherAETNA ELIGIBILITY ID
IN020047583OtherMEDICARE RAILROAD
IN5263695OtherAETNA ELIGIBILITY ID
IN266180005Medicare PIN