Provider Demographics
NPI:1407891922
Name:WAFFLE, CLARK M (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:M
Last Name:WAFFLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6814 90TH ST E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-6434
Mailing Address - Country:US
Mailing Address - Phone:253-841-0174
Mailing Address - Fax:
Practice Address - Street 1:407 14TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3770
Practice Address - Country:US
Practice Address - Phone:253-848-6661
Practice Address - Fax:253-770-5990
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00021479207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1002369Medicaid
WAA08716Medicare UPIN
WA1002369Medicaid