Provider Demographics
NPI:1770690430
Name:CLARK, WILLIAM S (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:S
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 MCHENRY AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5370
Mailing Address - Country:US
Mailing Address - Phone:818-398-8527
Mailing Address - Fax:209-254-7900
Practice Address - Street 1:1631 4TH ST
Practice Address - Street 2:
Practice Address - City:ESCALON
Practice Address - State:CA
Practice Address - Zip Code:95320-2007
Practice Address - Country:US
Practice Address - Phone:209-838-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002521A207P00000X
CA20A8748101YA0400X, 208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX87480Medicaid
CA00AX87480Medicaid