Provider Demographics
NPI:1659374007
Name:CLARK, LEO JP (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:JP
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1 SEAGATE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1558
Mailing Address - Country:US
Mailing Address - Phone:567-585-1983
Mailing Address - Fax:419-824-7359
Practice Address - Street 1:5705 MONCLOVA RD
Practice Address - Street 2:SUITE 204
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1875
Practice Address - Country:US
Practice Address - Phone:419-891-8045
Practice Address - Fax:419-891-8044
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2016-01-12
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Provider Licenses
StateLicense IDTaxonomies
OH35039317C207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH318954Medicaid
OHA75631Medicare UPIN
OHA75631Medicare UPIN