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NPI Code Detail

MEDICARE: GARRY ANDREW CLARK D.O.

MEDICARE: GARRY ANDREW CLARK D.O.
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
12081P2900XPain Medicine (Physical Medicine & Rehabilitation) Physician01361IA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
4CG1061OTHERIAMEDICARE RAILROAD GROUP NUMBER
5080082594OTHERIAMEDICARE RAILROAD INDIVIDUAL NUMBER

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
121964OTHERIAST LUKES GROUP PTAN
21528001492OTHERIAST LUKES GROUP NPI
321964001OTHERIAST LUKES INDIVIDUAL PTAN

General Provider Information

NPI Number : 1952380750
Entity Type Code : Individual
Provider Name (Legal Business Name) : GARRY ANDREW CLARK D.O.
Provider Business Mailing Address
First Line : 3930 STADIUM DR
Second Line :
City : SIOUX CITY
State : IA
Zip : 51106-5166
Country : US
Telephone Number : 712-276-4325
Fax Number : 712-276-6033
Provider Business Practice Location Address
First Line : 3930 STADIUM DR
Second Line :
City : SIOUX CITY
State : IA
Zip : 51106-5166
Country : US
Telephone Number : 712-276-4325
Fax Number : 712-276-6033
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/11/2006
Last Update Date : 01/26/2012

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Directions to “ GARRY ANDREW CLARK D.O.” Practice Location

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