Provider Demographics
NPI:1861684581
Name:CLARK, GRAHAM SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:GRAHAM
Middle Name:SCOTT
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 1:700 NE 87TH AVE
Mailing Address - Street 2:STE 370
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-397-3352
Mailing Address - Fax:360-604-1771
Practice Address - Street 1:2525 NE 139TH ST
Practice Address - Street 2:STE 240
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2719
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1726
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60250520207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002796100Medicaid
FL0471260003Medicare NSC