Provider Demographics
NPI:1265433940
Name:CLARK, DAVID W (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:W
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 411039
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-1039
Mailing Address - Country:US
Mailing Address - Phone:913-234-1350
Mailing Address - Fax:
Practice Address - Street 1:12300 METCALF AVE
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-1324
Practice Address - Country:US
Practice Address - Phone:913-317-7485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-27540207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208678029Medicaid
KS100317940CMedicaid
MO25062077OtherBCBS KC MO
KS01674018OtherBCBS OF KC MO GROUP ID #
MO25062057OtherBCBS OF KC MO
930066218OtherRR MEDICARE GROUP CG8899
P00188856OtherRR MEDICARE GROUP DC6712
KS100317940AMedicaid
KS100317940AMedicaid
MO208678029Medicaid
KS7637928Medicare PIN