Provider Demographics
NPI:1881736593
Name:CLARK, JOHN E
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08015R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1388483Medicaid
LA1388483Medicaid
LA55872Medicare PIN
LA250002036Medicare PIN