Provider Demographics
NPI:1396831178
Name:CLARK, LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:LOUISE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 NE TILLAMOOK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212
Mailing Address - Country:US
Mailing Address - Phone:503-282-2847
Mailing Address - Fax:
Practice Address - Street 1:2701 NW VAUGHN ST
Practice Address - Street 2:SUITE 140
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5398
Practice Address - Country:US
Practice Address - Phone:503-721-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR MD19137207Q00000X
WAMD00029505207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine