Provider Demographics
NPI:1023114576
Name:CLARK, STEVEN DONALD (PT)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:DONALD
Last Name:CLARK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 MORMON TREK BLVD
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52246-4435
Mailing Address - Country:US
Mailing Address - Phone:319-366-1886
Mailing Address - Fax:319-366-1611
Practice Address - Street 1:2220 MORMON TREK BLVD
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52246-4435
Practice Address - Country:US
Practice Address - Phone:319-366-1886
Practice Address - Fax:319-366-1611
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA028862251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665430Medicaid
IAIB1212007Medicare PIN
IAIB1213024Medicare PIN
IAIB1213Medicare PIN
IAIB1212Medicare PIN