Provider Demographics
NPI:1053316364
Name:CLARK, RICHARD DON (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DON
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:802 WAYNE ST
Practice Address - Street 2:STE 202
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3300
Practice Address - Country:US
Practice Address - Phone:740-374-4950
Practice Address - Fax:740-374-4953
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35061501207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000699782OtherANTHEM
OH000000120139OtherANTHEM
OH0827485Medicaid
WV0053603000Medicaid
D95379Medicare UPIN
OH7419371Medicare PIN
OH0699008Medicare PIN