Provider Demographics
NPI:1518936871
Name:CLARK, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
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:PO BOX 201868
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99520-1868
Mailing Address - Country:US
Mailing Address - Phone:907-770-2380
Mailing Address - Fax:907-770-2341
Practice Address - Street 1:3220 PROVIDENCE DR
Practice Address - Street 2:STE E3040
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-770-3750
Practice Address - Fax:907-770-3795
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3182207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD3182Medicaid
290009977OtherRAILROAD
AKMD3182Medicaid
290009977OtherRAILROAD
G16891Medicare UPIN