Provider Demographics
NPI:1740236579
Name:CLARK, DAVID P (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:P
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 1:300 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17046-4871
Mailing Address - Country:US
Mailing Address - Phone:717-273-8835
Mailing Address - Fax:
Practice Address - Street 1:300 WILLOW ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17046-4871
Practice Address - Country:US
Practice Address - Phone:717-273-8835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032198E207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC30492Medicare UPIN
PA131254Medicare ID - Type Unspecified