Provider Demographics
NPI:1407093875
Name:CLARK, WILLIAM TODD (CSA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:TODD
Last Name:CLARK
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 GREENBRIAR CT
Mailing Address - Street 2:
Mailing Address - City:OTISCO
Mailing Address - State:IN
Mailing Address - Zip Code:47163-9601
Mailing Address - Country:US
Mailing Address - Phone:812-256-6143
Mailing Address - Fax:
Practice Address - Street 1:305 GREENBRIAR CT
Practice Address - Street 2:
Practice Address - City:OTISCO
Practice Address - State:IN
Practice Address - Zip Code:47163-9601
Practice Address - Country:US
Practice Address - Phone:812-256-6143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant