Provider Demographics
NPI:1053350371
Name:CLARK, ALLAN B
Entity type:Individual
Prefix:DR
First Name:ALLAN
Middle Name:B
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 COUNTY ROAD 11 NW
Mailing Address - Street 2:
Mailing Address - City:PINE ISLAND
Mailing Address - State:MN
Mailing Address - Zip Code:55963-9756
Mailing Address - Country:US
Mailing Address - Phone:507-356-4929
Mailing Address - Fax:
Practice Address - Street 1:111 COUNTY ROAD 11 NW
Practice Address - Street 2:
Practice Address - City:PINE ISLAND
Practice Address - State:MN
Practice Address - Zip Code:55963-9756
Practice Address - Country:US
Practice Address - Phone:507-356-4929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29995207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine