Provider Demographics
NPI:1659629053
Name:CLACK, EDWARD PETERSEN (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:PETERSEN
Last Name:CLACK
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 1:5900 N MAIN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-3198
Mailing Address - Country:US
Mailing Address - Phone:937-277-9371
Mailing Address - Fax:937-277-7734
Practice Address - Street 1:5900 N MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-3198
Practice Address - Country:US
Practice Address - Phone:937-277-9371
Practice Address - Fax:937-277-7734
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.011463207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0122811Medicaid