Provider Demographics
NPI:1437278942
Name:CLARK, DONALD C (DC)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:C
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 SLATER RD STE 140
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-4049
Mailing Address - Country:US
Mailing Address - Phone:651-454-6367
Mailing Address - Fax:
Practice Address - Street 1:4660 SLATER RD STE 140
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-4049
Practice Address - Country:US
Practice Address - Phone:651-454-6367
Practice Address - Fax:651-454-8577
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1721111N00000X, 111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN645527100Medicaid