Provider Demographics
NPI:1346206430
Name:CLARK, CYNTHIA L (MD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:825 E 8TH ST STE 100
Practice Address - Street 2:
Practice Address - City:WINNER
Practice Address - State:SD
Practice Address - Zip Code:57580-2634
Practice Address - Country:US
Practice Address - Phone:605-842-2626
Practice Address - Fax:605-842-3557
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND5797207Q00000X
SD1151207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN711298000Medicaid
ND14513Medicaid
MN711298000Medicaid
ND713035Medicare PIN