Provider Demographics
NPI:1689611709
Name:CLARK, SAMUEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1940 EL CAJON BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-1005
Mailing Address - Country:US
Mailing Address - Phone:619-543-4500
Mailing Address - Fax:619-295-5600
Practice Address - Street 1:1940 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-1005
Practice Address - Country:US
Practice Address - Phone:619-543-4500
Practice Address - Fax:619-295-5600
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52335207RP1001X, 207R00000X, 207RC0200X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG10892Medicare UPIN