Provider Demographics
NPI:1780640730
Name:WARD, CLARK (MD)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:WARD
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 1:4500 S GARNETT RD
Mailing Address - Street 2:STE 300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5229
Mailing Address - Country:US
Mailing Address - Phone:918-664-9892
Mailing Address - Fax:918-664-2521
Practice Address - Street 1:4500 S GARNETT RD
Practice Address - Street 2:STE 300
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5229
Practice Address - Country:US
Practice Address - Phone:918-664-9892
Practice Address - Fax:918-664-2521
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK166532085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100030820AMedicaid
OKE78634Medicare UPIN
OK100030820AMedicaid
OK248516204Medicare PIN