Provider Demographics
NPI:1801864178
Name:CLARK, LAURIE C (DO)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14002 E 21ST ST STE 1130
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74134-1408
Mailing Address - Country:US
Mailing Address - Phone:918-439-1500
Mailing Address - Fax:918-439-1199
Practice Address - Street 1:14002 E 21ST ST STE 1130
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74134-1408
Practice Address - Country:US
Practice Address - Phone:918-439-1500
Practice Address - Fax:918-439-1199
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10664207Q00000X
IL036130673207Q00000X
OK2356207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100136290CMedicaid
OK249303803Medicare PIN
OKH57289Medicare UPIN