Basic Information
Provider Information
NPI: 1003017229
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CLARK
FirstName: DANIEL
MiddleName: JAMES
NamePrefix:  
NameSuffix:  
Credential: DO
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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: 12/05/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207L00000X4799AZN Allopathic & Osteopathic PhysiciansAnesthesiology 
207L00000XOP 60011959WAN Allopathic & Osteopathic PhysiciansAnesthesiology 
207L00000X20A10260CAN Allopathic & Osteopathic PhysiciansAnesthesiology 
207L00000XE-5858ARN Allopathic & Osteopathic PhysiciansAnesthesiology 
207L00000X4708OKY Allopathic & Osteopathic PhysiciansAnesthesiology 
390200000X ARN Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


Home