Provider Demographics
NPI: | 1477596773 |
---|---|
Name: | CLARK, RICHARD F (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | RICHARD |
Middle Name: | F |
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: | FILE NO 54826 |
Mailing Address - Street 2: | |
Mailing Address - City: | LOS ANGELES |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90074-4826 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 888-486-4380 |
Mailing Address - Fax: | 562-468-0347 |
Practice Address - Street 1: | 9300 CAMPUS POINT DRIVE |
Practice Address - Street 2: | |
Practice Address - City: | LA JOLLA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92037 |
Practice Address - Country: | US |
Practice Address - Phone: | 858-657-7000 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-14 |
Last Update Date: | 2023-05-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | G71265 | 207PT0002X, 207P00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | |
No | 207PT0002X | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 00G712650 | Medicaid | |
CA | 00G712650 | Medicaid | |
E90570 | Medicare UPIN | ||
CA | WG71265F | Medicare ID - Type Unspecified |