Provider Demographics
NPI:1750318812
Name:CLARK, ELLIS RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:RICHARD
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:PO BOX 4008
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4008
Mailing Address - Country:US
Mailing Address - Phone:503-372-2740
Mailing Address - Fax:503-372-2754
Practice Address - Street 1:700 BELLEVUE ST SE
Practice Address - Street 2:SUITE 300
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3819
Practice Address - Country:US
Practice Address - Phone:503-364-3704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15586207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022509Medicaid
OR0000BHXSFMedicare ID - Type Unspecified
C94161Medicare UPIN