Provider Demographics
NPI:1255566220
Name:CLARK, AMBER M (MD)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1321 NE 99TH AVE
Practice Address - Street 2:STE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9436
Practice Address - Country:US
Practice Address - Phone:503-215-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORMD162440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01296606OtherRR MEDICARE - PH&S - OREGON (PMG)
OR500662211Medicaid
ORG8952063Medicare PIN
ORR172089Medicare PIN
OR500662211Medicaid
ORR172094Medicare PIN
ORR172090Medicare PIN
WAG8926286Medicare PIN
ORR172091Medicare PIN
ORR172088Medicare PIN