Provider Demographics
NPI:1619908589
Name:LORI CLARK M.D., INC.
Entity Type:Organization
Organization Name:LORI CLARK M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-588-7262
Mailing Address - Street 1:23521 PASEO DE VALENCIA STE 108
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3137
Mailing Address - Country:US
Mailing Address - Phone:949-588-7262
Mailing Address - Fax:949-588-7260
Practice Address - Street 1:23521 PASEO DE VALENCIA STE 108
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3137
Practice Address - Country:US
Practice Address - Phone:949-588-7262
Practice Address - Fax:949-588-7260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82608207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A826080OtherBLUE SHIELD OF CA
CA00A826080Medicaid
CA00A82608OtherCALOPTIMA DIRECT
CA00A826080OtherBLUE SHIELD OF CA
CA00A826080Medicaid