Provider Demographics
NPI:1629230479
Name:CLARK, DAVID FREDERICK (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:FREDERICK
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 1:12140 NALL AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-2503
Mailing Address - Country:US
Mailing Address - Phone:913-661-9448
Mailing Address - Fax:913-661-4688
Practice Address - Street 1:12140 NALL AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-2503
Practice Address - Country:US
Practice Address - Phone:913-661-9448
Practice Address - Fax:913-661-4688
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
KS04364052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program