Provider Demographics
NPI:1326008277
Name:CLARK, TERRY L (DPM)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1127
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53082-1127
Mailing Address - Country:US
Mailing Address - Phone:920-457-6750
Mailing Address - Fax:920-457-8350
Practice Address - Street 1:728 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4669
Practice Address - Country:US
Practice Address - Phone:920-803-8014
Practice Address - Fax:920-803-8015
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI649-025213E00000X
UT105334-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43213700Medicaid
WI43213700Medicaid