Provider Demographics
NPI:1336385533
Name:OWEN E CLARK MD INC PS
Entity Type:Organization
Organization Name:OWEN E CLARK MD INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-523-6798
Mailing Address - Street 1:10010 41ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-8106
Mailing Address - Country:US
Mailing Address - Phone:206-523-6798
Mailing Address - Fax:
Practice Address - Street 1:10010 41ST AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-8106
Practice Address - Country:US
Practice Address - Phone:206-523-6798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA12909261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAO4263Medicare UPIN