Provider Demographics
NPI:1619952421
Name:CLARK, DAVID A (MD, MEDICAL CORP)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD, MEDICAL CORP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 CASS ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-2947
Mailing Address - Country:US
Mailing Address - Phone:831-649-9330
Mailing Address - Fax:831-649-9335
Practice Address - Street 1:880 CASS ST
Practice Address - Street 2:SUITE 108
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-2947
Practice Address - Country:US
Practice Address - Phone:831-649-9330
Practice Address - Fax:831-649-9335
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG12303207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G123035OtherMEDICARE INDIV-STAN PTAN
CA06E9948OtherCHAMPUS
CAZZZ39341ZOtherMEDICARE GRP PTAN
CAGR0057973Medicaid
CA00G123034OtherMEDICARE INDIVIDUAL PTAN
CAZZZ04915ZOtherMEDICARE GRP-STAN PTAN
CAZZZ04915ZOtherMEDICARE GRP-STAN PTAN