Provider Demographics
NPI:1134539091
Name:CLARK, KELLAN FITZGERALD (DO)
Entity type:Individual
Prefix:
First Name:KELLAN
Middle Name:FITZGERALD
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 WESTWOOD DR STE F
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2345
Practice Address - Country:US
Practice Address - Phone:406-375-2930
Practice Address - Fax:406-375-4525
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-71931208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1134539091Medicaid
MT100004016Medicaid