Provider Demographics
NPI:1669424917
Name:CLACK, SUSAN M (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:CLACK
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 1:13200 SW PACIFIC HWY
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-4828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13200 SW PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223
Practice Address - Country:US
Practice Address - Phone:503-598-2000
Practice Address - Fax:503-639-0920
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14435207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR142307Medicaid
08118136OtherRR PIN
ORC91319Medicare UPIN
08118136OtherRR PIN