Provider Demographics
NPI:1568490662
Name:CLARK, HOWARD BRENT (MD)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:BRENT
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:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:420 DELAWARE STREET SE, MMC 609
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-0622
Mailing Address - Fax:612-626-2696
Practice Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - Street 2:420 DELAWARE STREET SE, 760 MAYO MEMORIAL BUILDING
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-626-0622
Practice Address - Fax:612-626-2696
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33386207ZN0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN101350OtherUCARE
WI32008600Medicaid
MNHP22280OtherHEALTHPARTNERS
MN2T209CLOtherBCBS
MN768064OtherARAZ
MN11-74537OtherMEDICA PRIMARY
MN876505700Medicaid
MN1009073OtherPREFERRED ONE
MN11-22542OtherMEDICA CHOICE
MNHP22280OtherHEALTHPARTNERS
MN220000282Medicare ID - Type UnspecifiedMN MEDICARE