Provider Demographics
NPI:1417937145
Name:CLARK, GORDON BLAKE (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:BLAKE
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 1:21624 MIDLAND DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66218-9064
Mailing Address - Country:US
Mailing Address - Phone:913-643-0075
Mailing Address - Fax:913-643-0077
Practice Address - Street 1:21624 MIDLAND DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66218-9064
Practice Address - Country:US
Practice Address - Phone:913-643-0075
Practice Address - Fax:913-643-0077
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS 04-23518207V00000X
KS04-23518207VB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VB0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObesity Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100305190DMedicaid
KSP868019Medicare ID - Type Unspecified
KSG25880Medicare UPIN