Provider Demographics
NPI:1407893795
Name:CLARK, KIRBY P (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRBY
Middle Name:P
Last Name:CLARK
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:PO BOX 2758
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2758
Mailing Address - Country:US
Mailing Address - Phone:319-235-5390
Mailing Address - Fax:
Practice Address - Street 1:4006 JOHNATHAN ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-9387
Practice Address - Country:US
Practice Address - Phone:319-236-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42049-202085R0202X
IL0361264572085R0202X
IA359562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G96713Medicare UPIN