Healthcare Provider Details

I. General information

NPI: 1336317239
Provider Name (Legal Business Name): RALPH WARNER CLARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST 116A/MAIN
LOMA LINDA CA
92357-1000
US

IV. Provider business mailing address

11201 BENTON ST
LOMA LINDA CA
92357-1000
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax: 909-422-3168
Mailing address:
  • Phone: 909-825-7084
  • Fax: 909-422-3168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberA111705
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberA111705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: