Provider Demographics
NPI:1376506642
Name:CLARK, KEITH FREDRICK (MD PHD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:FREDRICK
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 NW 9TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-1070
Mailing Address - Country:US
Mailing Address - Phone:405-272-6027
Mailing Address - Fax:405-272-8315
Practice Address - Street 1:535 NW 9TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-1070
Practice Address - Country:US
Practice Address - Phone:405-272-6027
Practice Address - Fax:405-272-8315
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14220207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157107001Medicaid
731461178005OtherTRICARE
A0209ZOtherPPO OKLAHOMA
OK100823600BMedicaid
2994975OtherAETNA US HEALTHCARE
P00075512OtherRR MEDICARE
A0209ZOtherPPO OKLAHOMA
A02092Medicare UPIN