Basic Information
| Provider Information | |||||||||
| NPI: | 1003017229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5665 NEW NORTHSIDE DR | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303285831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708745400 | ||||||||
| FaxNumber: | 7708745483 | ||||||||
| Practice Location | |||||||||
| Address1: | 5330 S HIGHWAY 95 | ||||||||
| Address2: | |||||||||
| City: | FORT MOHAVE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864269225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287887115 | ||||||||
| FaxNumber: | 7708745483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 4708 | OK | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | E-5858 | AR | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | OP 60011959 | WA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 4799 | AZ | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 20A10260 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.