Healthcare Provider Details

I. General information

NPI: 1679522924
Provider Name (Legal Business Name): DAVID W CLARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 PARKVIEW CIRCLE DR SUITE 310
FORT WAYNE IN
46845-1672
US

IV. Provider business mailing address

1234 E DUPONT RD SUITE 1
FORT WAYNE IN
46825-1545
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-5230
  • Fax: 260-266-5238
Mailing address:
  • Phone: 260-373-9965
  • Fax: 260-458-5664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01037790
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: