Provider Demographics
NPI:1518740091
Name:CLARK FAMILY MEDICINE
Entity Type:Organization
Organization Name:CLARK FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-595-6976
Mailing Address - Street 1:1246 YELLOWSTONE AVE STE A2
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4372
Mailing Address - Country:US
Mailing Address - Phone:208-595-6976
Mailing Address - Fax:208-480-9590
Practice Address - Street 1:1246 YELLOWSTONE AVE STE A2
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4372
Practice Address - Country:US
Practice Address - Phone:208-595-6976
Practice Address - Fax:208-480-9590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty