MEDICARE: DR. GREGORY O'NEAL CLARK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	336.093729	IL

General Provider Information

NPI Number	:	1053363952
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY O'NEAL CLARK M.D.

Provider Business Mailing Address
First Line	:	920 GRANDVIEW LN
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-3914
Country	:	US
Telephone Number	:	443-823-0583
Fax Number	:

Provider Business Practice Location Address
First Line	:	355 W DUNDEE RD STE 110
Second Line	:
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-3500
Country	:	US
Telephone Number	:	847-541-4878
Fax Number	:	847-520-0500

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	07/26/2023

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