Provider Demographics
NPI:1790898450
Name:CLARK, HENRY VONDELL (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:VONDELL
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:MADIGAN ARMY MEDICAL CENTER
Mailing Address - Street 2:9040 JACKSON AVE.
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431
Mailing Address - Country:US
Mailing Address - Phone:253-968-2252
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-9361
Practice Address - Country:US
Practice Address - Phone:253-968-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11521OtherBCBS PROVIDER NUMBER
NC1790898450Medicaid
NC9800216OtherLICENSE - NC
NC9800216OtherLICENSE - NC
NC9800216OtherLICENSE - NC
NCG82029Medicare UPIN
NC2257961AMedicare Oscar/Certification