Provider Demographics
NPI:1629335534
Name:CLARK, SIMON (DO)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 JEFFERSON HWY
Mailing Address - Street 2:APARTMENT # 2107
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-8175
Mailing Address - Country:US
Mailing Address - Phone:816-769-3200
Mailing Address - Fax:
Practice Address - Street 1:6810 JEFFERSON HWY
Practice Address - Street 2:APT 2107
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-8175
Practice Address - Country:US
Practice Address - Phone:816-769-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2015016613207P00000X
LAD.O. 0000343207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program