Provider Demographics
NPI:1265546014
Name:CLARK, GORDON H (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:H
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 1:2314 S RANGE AVE
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-5216
Mailing Address - Country:US
Mailing Address - Phone:225-480-4080
Mailing Address - Fax:877-485-4275
Practice Address - Street 1:2314 S RANGE AVE
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-5216
Practice Address - Country:US
Practice Address - Phone:225-480-4080
Practice Address - Fax:877-485-4275
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19473207Q00000X
CODR.0059785207Q00000X
LAMD 203009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1066656Medicaid
LA5M480DE56Medicare PIN
LA4M480C822Medicare PIN
LA4M480DL13Medicare PIN