MEDICARE: DR. DOUGLAS GEORGE 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	207R00000X	Internal Medicine Physician	G050862	CA

General Provider Information

NPI Number	:	1780688572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS GEORGE CLARK M.D.

Provider Business Mailing Address
First Line	:	12665 GARDEN GROVE BLVD
Second Line	:	SUITE 301
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843-1901
Country	:	US
Telephone Number	:	714-530-7373
Fax Number	:	714-530-7940

Provider Business Practice Location Address
First Line	:	12665 GARDEN GROVE BLVD
Second Line	:	SUITE 301
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843-1901
Country	:	US
Telephone Number	:	714-530-7373
Fax Number	:	714-530-7940

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	12/27/2007

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