Provider Demographics
NPI:1316579022
Name:BROWN, CLARK EDWARD
Entity Type:Individual
Prefix:MR
First Name:CLARK
Middle Name:EDWARD
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181309 N 2650 RD
Mailing Address - Street 2:
Mailing Address - City:WALTERS
Mailing Address - State:OK
Mailing Address - Zip Code:73572-3913
Mailing Address - Country:US
Mailing Address - Phone:580-351-8315
Mailing Address - Fax:
Practice Address - Street 1:181309 N 2650 RD
Practice Address - Street 2:
Practice Address - City:WALTERS
Practice Address - State:OK
Practice Address - Zip Code:73572-3913
Practice Address - Country:US
Practice Address - Phone:580-351-8315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKGAAA-NJRV-HY5Z2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKGAAA-NJRV-HY5ZOtherOMMA