MEDICARE: DENNIS L 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
1	207R00000X	Internal Medicine Physician	G25400	CA

General Provider Information

NPI Number	:	1699700849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS L CLARK MD

Provider Business Mailing Address
First Line	:	3816 WOODRUFF AVE
Second Line	:	SUITE 401
City	:	LONG BEACH
State	:	CA
Zip	:	90808-2147
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3816 WOODRUFF AVE
Second Line	:	SUITE 401
City	:	LONG BEACH
State	:	CA
Zip	:	90808-2147
Country	:	US
Telephone Number	:	562-420-8679
Fax Number	:

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	09/07/2007

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