Provider Demographics
NPI:1679522924
Name:CLARK, DAVID W (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:W
Last Name:CLARK
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9965
Mailing Address - Fax:260-458-5664
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR
Practice Address - Street 2:SUITE 310
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1672
Practice Address - Country:US
Practice Address - Phone:260-266-5230
Practice Address - Fax:260-266-5238
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2013-10-10
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Provider Licenses
StateLicense IDTaxonomies
IN01037790207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200015230Medicaid
IN000000672225OtherANTHEM
INM400025740Medicare PIN
IN200015230Medicaid
IN925060BMedicare PIN