Provider Demographics
NPI:1477572097
Name:CLARK, LYLE ARTHUR (MD)
Entity Type:Individual
Prefix:DR
First Name:LYLE
Middle Name:ARTHUR
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 1:900 E LA HARPE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4520
Mailing Address - Country:US
Mailing Address - Phone:660-665-1962
Mailing Address - Fax:660-665-3989
Practice Address - Street 1:141 COMMUNICATION DRIVE
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401
Practice Address - Country:US
Practice Address - Phone:573-795-7342
Practice Address - Fax:573-248-3080
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8E552084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208444604Medicaid
MO137050069Medicare ID - Type Unspecified
MOA13249Medicare UPIN