Provider Demographics
NPI:1710265160
Name:CLARK, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6646 HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:GERALD
Mailing Address - State:MO
Mailing Address - Zip Code:63037-2700
Mailing Address - Country:US
Mailing Address - Phone:573-764-5707
Mailing Address - Fax:573-764-5207
Practice Address - Street 1:6646 HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:GERALD
Practice Address - State:MO
Practice Address - Zip Code:63037-2700
Practice Address - Country:US
Practice Address - Phone:573-764-5707
Practice Address - Fax:573-764-5207
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other