Provider Demographics
NPI:1710349592
Name:CLARK, JOSHUA (MD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
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 1:360 S GARDEN WAY
Mailing Address - Street 2:STE 230
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-8187
Mailing Address - Country:US
Mailing Address - Phone:541-747-6159
Mailing Address - Fax:541-741-7249
Practice Address - Street 1:1605 G ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4227
Practice Address - Country:US
Practice Address - Phone:541-747-6159
Practice Address - Fax:458-201-8510
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD197684207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program