Provider Demographics
NPI:1679572796
Name:CLARK, ANDREW BURNHAM (DPM)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:BURNHAM
Last Name:CLARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 FORD ST
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1947
Mailing Address - Country:US
Mailing Address - Phone:419-893-5539
Mailing Address - Fax:419-893-6853
Practice Address - Street 1:609 FORD ST
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1947
Practice Address - Country:US
Practice Address - Phone:419-893-5539
Practice Address - Fax:419-893-6853
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.002902213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0321182Medicaid
000000135414OtherANTHEM
OH02222OtherPARAMOUNT
OH02222OtherPARAMOUNT
OH0537250004Medicare NSC
OH480020310Medicare PIN
OHCL0801892Medicare PIN
OH0537250002Medicare NSC
000000135414OtherANTHEM
OHCL0801891Medicare PIN