Provider Demographics
NPI:1497833511
Name:CLARK, DANIEL LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14831 W 159TH ST
Mailing Address - Street 2:HARRIS BANK BUILDING
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60491
Mailing Address - Country:US
Mailing Address - Phone:815-838-0052
Mailing Address - Fax:815-838-4410
Practice Address - Street 1:14831 W 159TH ST
Practice Address - Street 2:HARRIS BANK BUILDING
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60491
Practice Address - Country:US
Practice Address - Phone:815-838-0052
Practice Address - Fax:815-838-4410
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036071157207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0991512865OtherBCBS
779990Medicare ID - Type Unspecified
C43055Medicare UPIN