Provider Demographics
NPI:1265722342
Name:CLARK, CALVIN CLAYTON (MD)
Entity type:Individual
Prefix:DR
First Name:CALVIN
Middle Name:CLAYTON
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 1:6701 SE EVERGREEN HWY
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661
Mailing Address - Country:US
Mailing Address - Phone:360-695-0563
Mailing Address - Fax:
Practice Address - Street 1:6701 SE EVERGREEN HWY
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661
Practice Address - Country:US
Practice Address - Phone:360-695-0563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA9351208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics