Provider Demographics
NPI:1841380870
Name:CLARK, DAVID C (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 GENESEE STREET
Mailing Address - Street 2:BUSINESS OFFICE ROOM 315
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5930
Mailing Address - Country:US
Mailing Address - Phone:315-801-3282
Mailing Address - Fax:315-801-8391
Practice Address - Street 1:8411 SENECA TPKE
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-4912
Practice Address - Country:US
Practice Address - Phone:315-624-8500
Practice Address - Fax:315-624-8515
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165574207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA6413Medicare PIN
NYF10384Medicare UPIN