Provider Demographics
NPI:1023052545
Name:CLARK, CHAD LEROY (MD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:LEROY
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:PO BOX 661987
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-1987
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:3865 JACKSON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3919
Practice Address - Country:US
Practice Address - Phone:951-352-5666
Practice Address - Fax:951-352-5445
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70662207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A706620Medicaid
CA00A706622Medicare PIN
CAH18838Medicare UPIN
CA00A706623Medicare PIN