Provider Demographics
NPI:1831182757
Name:ANTONSON, CLARK W (MD)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:W
Last Name:ANTONSON
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 1:4545 R ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68503-3723
Mailing Address - Country:US
Mailing Address - Phone:402-465-4545
Mailing Address - Fax:402-465-3621
Practice Address - Street 1:4545 R ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68503-3723
Practice Address - Country:US
Practice Address - Phone:402-465-4545
Practice Address - Fax:402-465-3621
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17282174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE260520ANMedicare ID - Type Unspecified
NEE56847Medicare UPIN
NEO97850Medicare ID - Type Unspecified