Provider Demographics
NPI:1932420320
Name:CLARK, TIMOTHY VAUGHAN (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:VAUGHAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
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 3067
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95992-3067
Mailing Address - Country:US
Mailing Address - Phone:207-939-4204
Mailing Address - Fax:
Practice Address - Street 1:726 4TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5656
Practice Address - Country:US
Practice Address - Phone:530-743-4377
Practice Address - Fax:530-749-6616
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-20
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13845207RC0200X
PAOTO13674207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A13845OtherLICENSE