Provider Demographics
NPI:1588625123
Name:CLARK, JOHN H (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
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 1:3 GATES CIR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-1120
Mailing Address - Country:US
Mailing Address - Phone:716-887-4690
Mailing Address - Fax:
Practice Address - Street 1:3 GATES CIR
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-1120
Practice Address - Country:US
Practice Address - Phone:716-887-4690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124036207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BB1082Medicare ID - Type Unspecified
C49538Medicare UPIN