Provider Demographics
NPI:1760667935
Name:CLARK W PILLSBURY, DPM, LLC
Entity Type:Organization
Organization Name:CLARK W PILLSBURY, DPM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:PILLSBURY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:775-358-2542
Mailing Address - Street 1:10463 DOUBLE R BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-8908
Mailing Address - Country:US
Mailing Address - Phone:775-358-2542
Mailing Address - Fax:775-358-1413
Practice Address - Street 1:10463 DOUBLE R BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-8908
Practice Address - Country:US
Practice Address - Phone:775-358-2542
Practice Address - Fax:775-358-1413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8801213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002116004Medicaid
NVT67323Medicare UPIN
NV002116004Medicaid
NV4554910001Medicare NSC