Basic Information
Provider Information
NPI: 1033557269
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CLARK
FirstName: SPENCER
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3300 NW EXPWY
Address2:  
City: OKLAHOMA CITY
State: OK
PostalCode: 731124418
CountryCode: US
TelephoneNumber: 4059512277
FaxNumber:  
Practice Location
Address1: 3300 NW EXPWY
Address2:  
City: OKLAHOMA CITY
State: OK
PostalCode: 731124418
CountryCode: US
TelephoneNumber: 4059512277
FaxNumber: 7023888431
Other Information
ProviderEnumerationDate: 06/10/2013
LastUpdateDate: 06/20/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000XSL0944NVY Other Service ProvidersSpecialist 

No ID Information.


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