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NPI Code Detail

MEDICARE: EDWARD CLARK MD

MEDICARE: EDWARD CLARK MD
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
1207Q00000XFamily Medicine Physician11309NV

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
411309OTHERNVNV LICENSE
511309OTHERNVSTATE LICENSE

General Provider Information

NPI Number : 1356318174
Entity Type Code : Individual
Provider Name (Legal Business Name) : EDWARD CLARK MD
Provider Business Mailing Address
First Line : 6355 S BUFFALO DR FL 3
Second Line :
City : LAS VEGAS
State : NV
Zip : 89113-2133
Country : US
Telephone Number : 702-216-3346
Fax Number : 702-671-6883
Provider Business Practice Location Address
First Line : 595 W LAKE MEAD PKWY
Second Line :
City : HENDERSON
State : NV
Zip : 89015-7015
Country : US
Telephone Number : 702-565-1007
Fax Number : 702-565-0836
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/01/2006
Last Update Date : 10/17/2022

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Directions to “ EDWARD CLARK MD” Practice Location

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