=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073257887
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL CLARK DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2022
-----------------------------------------------------
Last Update Date | 05/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 NOTTINGHAM RD
-----------------------------------------------------
City | JAMESVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13078-8705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-445-9242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4795 GLENCREST AVE
-----------------------------------------------------
City | LIVERPOOL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13088-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 131-540-6304
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 047002
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2305215645
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------