Provider Demographics
NPI:1780666594
Name:CLARK, CRAIG B (DO)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:B
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1301 PENN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50316-2350
Mailing Address - Country:US
Mailing Address - Phone:515-263-2400
Mailing Address - Fax:515-263-2540
Practice Address - Street 1:1301 PENN AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-2364
Practice Address - Country:US
Practice Address - Phone:515-263-2400
Practice Address - Fax:515-263-2540
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA03037207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1780666594Medicaid
IA1240796Medicaid
IAI6398Medicare ID - Type Unspecified
IA719260383Medicare PIN
IAI8659002Medicare PIN
IA1240796Medicaid