Provider Demographics
NPI:1346213626
Name:CLARK, EDWIN ALLEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:ALLEN
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1501 ALDERSGATE RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6611
Mailing Address - Country:US
Mailing Address - Phone:501-224-1501
Mailing Address - Fax:501-376-7065
Practice Address - Street 1:1501 ALDERSGATE RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6611
Practice Address - Country:US
Practice Address - Phone:501-224-1501
Practice Address - Fax:501-376-7065
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR89213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
480017088OtherRR MEDICARE
AR56081OtherFIRST SOURCE PPO
AR56081OtherBLUE CROSS SHIELD
AR56081OtherBCBS FEP
AR56081OtherBLUE ADVANTAGE
AR109956017Medicaid
AR56081OtherHEALTH ADVANTAGE
AR56081Medicare PIN
AR56081OtherFIRST SOURCE PPO
T20353Medicare UPIN
AR560817258Medicare Oscar/Certification