Provider Demographics
NPI:1780688572
Name:CLARK, DOUGLAS GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:GEORGE
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:12665 GARDEN GROVE BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1901
Mailing Address - Country:US
Mailing Address - Phone:714-530-7373
Mailing Address - Fax:714-530-7940
Practice Address - Street 1:12665 GARDEN GROVE BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1901
Practice Address - Country:US
Practice Address - Phone:714-530-7373
Practice Address - Fax:714-530-7940
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-12-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG050862207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG50862FMedicare PIN