Provider Demographics
NPI:1952380750
Name:CLARK, GARRY ANDREW (DO)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:ANDREW
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 1:3930 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-5166
Mailing Address - Country:US
Mailing Address - Phone:712-276-4325
Mailing Address - Fax:712-276-6033
Practice Address - Street 1:3930 STADIUM DR
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-5166
Practice Address - Country:US
Practice Address - Phone:712-276-4325
Practice Address - Fax:712-276-6033
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA013612081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA21964OtherST LUKES GROUP PTAN
IA1528001492OtherST LUKES GROUP NPI
IA21964001OtherST LUKES INDIVIDUAL PTAN
IACG1061OtherMEDICARE RAILROAD GROUP NUMBER
IA080082594OtherMEDICARE RAILROAD INDIVIDUAL NUMBER
IA21964OtherST LUKES GROUP PTAN
IAO46455Medicare UPIN