Provider Demographics
NPI:1598838799
Name:CLARK, WILLIAM HENRY
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:HENRY
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 N BEVERLY AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2154
Mailing Address - Country:US
Mailing Address - Phone:520-323-7026
Mailing Address - Fax:520-323-0301
Practice Address - Street 1:2121 N BEVERLY AVE STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2154
Practice Address - Country:US
Practice Address - Phone:520-323-7026
Practice Address - Fax:520-323-0301
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7474207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000BGJCQMedicare ID - Type Unspecified
D43783Medicare UPIN