Healthcare Provider Details

I. General information

NPI: 1831159631
Provider Name (Legal Business Name): CLARK WARDEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7015 HWY 190 E SERV RD SUITE 200
COVINGTON LA
70433-4960
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 985-234-3000
  • Fax: 985-234-3002
Mailing address:
  • Phone: 985-234-3000
  • Fax: 225-526-0636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number017994
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: