Provider Demographics
NPI:1700863701
Name:CLARK, RICHARD ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALAN
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 1:7219 N LITCHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LUKE AFB HOSPITAL
Mailing Address - State:AZ
Mailing Address - Zip Code:85309-1525
Mailing Address - Country:US
Mailing Address - Phone:623-856-3763
Mailing Address - Fax:
Practice Address - Street 1:7219 N LITCHFIELD RD
Practice Address - Street 2:
Practice Address - City:LUKE AFB HOSPITAL
Practice Address - State:AZ
Practice Address - Zip Code:85309-1525
Practice Address - Country:US
Practice Address - Phone:623-856-3763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29948207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine