Provider Demographics
NPI:1538123385
Name:CLARK, STEPHEN JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JAMES
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 1:3021 FALLING WATERS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-6793
Mailing Address - Country:US
Mailing Address - Phone:847-356-9300
Mailing Address - Fax:847-356-6781
Practice Address - Street 1:3021 FALLING WATERS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-6793
Practice Address - Country:US
Practice Address - Phone:847-356-9300
Practice Address - Fax:847-356-6781
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083190207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILB52107Medicare UPIN
IL625120Medicare ID - Type Unspecified