Provider Demographics
NPI:1790850758
Name:CLARK, TODD K A (MSPT)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:K A
Last Name:CLARK
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1440
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-1440
Mailing Address - Country:US
Mailing Address - Phone:808-262-2292
Mailing Address - Fax:808-262-2293
Practice Address - Street 1:1090 KEOLU DR
Practice Address - Street 2:SUITE 104
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-3871
Practice Address - Country:US
Practice Address - Phone:808-262-2292
Practice Address - Fax:808-262-2293
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1978225100000X
HIPT1978225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist