Healthcare Provider Details

I. General information

NPI: 1699712000
Provider Name (Legal Business Name): RONALD LARSON CLARKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14279 GLEN OAK RD
OREGON CITY OR
97045-8008
US

IV. Provider business mailing address

5178 NELCO CT
WEST LINN OR
97068-2906
US

V. Phone/Fax

Practice location:
  • Phone: 503-657-7629
  • Fax: 503-557-8651
Mailing address:
  • Phone: 503-557-9384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD16593
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier009496
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier67972000
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: