Provider Demographics
NPI:1811166150
Name:JOHN E. CLARK,M.D., LTD
Entity type:Organization
Organization Name:JOHN E. CLARK,M.D., LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-766-2311
Mailing Address - Street 1:PO BOX 84358
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70884-4358
Mailing Address - Country:US
Mailing Address - Phone:225-766-2311
Mailing Address - Fax:225-767-7134
Practice Address - Street 1:4545 BLUEBONNET BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-5600
Practice Address - Country:US
Practice Address - Phone:225-766-2311
Practice Address - Fax:225-767-7134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08015R208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1388483Medicaid
LA250002036Medicare PIN
LA5D855Medicare PIN
LAD83723Medicare UPIN