Provider Demographics
NPI:1205436227
Name:CLARK, ANGEL A (DPH)
Entity type:Individual
Prefix:DR
First Name:ANGEL
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11640 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-5621
Mailing Address - Country:US
Mailing Address - Phone:918-289-9142
Mailing Address - Fax:
Practice Address - Street 1:207 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74112-2201
Practice Address - Country:US
Practice Address - Phone:918-838-2937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13578183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist